Obstetrics

Dr. Riley Harrison

Contents
Pregnancy counselling & Infections
• Normal pregnancy counselling *****
• Pregnancy with diabetes (before, early pregnancy),****
• Pregnancy with SLE **
• Elderly pregnancy with obesity*****
• Rubella contact****
• Lithium taking mother *
• HIV in pregnancy *
• Anaemia in pregnancy*****
• Murmur in pregnancy*
• Twin pregnancy*
• Transverse lie*
• Plan for pregnancy after repeated abortions*
• GBS positive in urine*****
• HSV in pregnancy****
• NIPT ****
• Pyelonephritis *****
• Itchy rash in pregnancy ***
Early pregnancy complications
• Bleeding in early pregnancy ([Link], threatened miscarriage, incomplete miscarriage, Ectopic
pregnancy)*
• Abdominal pain in early pregnancy*
• Hyperemesis gravidarum****
Mode of delivery
• CS counselling****
• VBAC***
• Induction of labour**
Complications of pregnancy
• Pregnancy induced hypertension*
• Pre-eclampsia*****
• Eclampsia**
• Premature labour**
• PROM/PPROM****
• Large for date**
• Small for date**
• Placenta praevia 1**
• Placenta praevia 2*****
• Abruptio placentae*
• MVA during pregnancy*
Post Partum Cases
• Primary PPH*
• Secondary PPH***
• Puerperial pyrexia (Mastitis/Endometritis) ****
Normal pregnancy counselling
Your next patient in a GP is a 24-year-old lady who is planning her first pregnancy and she wants your
advice.
Your tasks :
• History
• explain about AN care and it's management
• give advice to her regarding pregnancy

History
Hello! Today you want to know about AN care.
• By the way, are you going to start family life? I need to ask you a few questions as a routine.
how long have you been here in Australia? May I know your ethnic origin? How about your
husband? When will you be pregnant?
• Period : how about your period? When was the last period? What's your period regular? Any
pain or bleeding between your period?
• Pregnancy : have you ever been pregnant before? Any history of miscarriage?
• Pills : Are you on contraception? Which one? For how long?
• Partner : Let me ask you a few sensitive and private questions do you have a stable partner? Do
you practice safe sex? Any chance that you or your partner diagnosed with sexually transmitted
infections?
• Pap Test : In Australia we recommend cervical screening test? Have you ever done your pap
test? When was your last Pap test? What was the result?
• Do you know your blood group and Rh status? How about your immunization status? have you
ever exposed to a child with acute infection with rubella or chickenpox recently?
• Medical History : Are you generally healthy? Do you have any chronic medical problem? Like
diabetes, raised blood pressure, heart disease, kidney problems, joint problems, clotting
problems(DVT)
• any history of multiple pregnancies?
• Social : With whom do you live? Is your partner supportive? Any blood relation between you
and your partner? What do you do for a living?
• SADMA : Do you smoke? How about alcohol? Do you have any medications taking regularly?

Advice
• Thank you so much for your information.
• According to your story, you seem healthy. Let me explain you about pre-pregnancy care and
management plan routinely done in pregnancy. Our aim is to make sure both mom and baby are
healthy. Before I explain, I will do quick examination on you, to make sure you are physically fit
to be pregnant. I need to give you some advice for your pregnancy.
• First of all, you need to maintain healthy diet. You can enjoy healthy fruits and vegetables but
eat dairy products caution. Eat less sugar, salty food, cheese, butter.
• Avoid any food that might be contaminated with infection we call listeria which might be
harmful to the fetus. Listeria usually seen in dairy products, raw vegetables, meat, seafoods,
especially in foods that stored in the fridge for long. Before you eat fruit and vegetables, clean
with water and avoid uncooked foods.
• I would also suggest you optimal weight control. Obesity during pregnancy cause lots of impacts
during pregnancy and delivery. You can do regular exercise like walking and swimming.
• Also I would like to prescribe you folic acid in 0.5 mg. As part of the antenatal checkup, I will do
some blood test including full blood examination, Liver and kidney functions, blood grouping
and matching, rubella antibodies and infection serology and urine tests so you can be pregnant
as soon as possible.
• At 18 weeks of gestation, we will do the ultrasound imaging to assess baby’s condition and
amount of fluids around the baby and identify placenta position. At 28 weeks, you will need to
have sweet drink test to screen possibility of diabetes during pregnancy.
• At 36 weeks, we have to collect the swab from your down below to check the organisms or the
bugs we call it group B streptococcus which can influence treatment on delivery.
• For patient with some risks, we have screening tests that can be done in pregnancy if needed.
For example, genetically run diseases like down syndrome and brain defects. You don't have any
genetic diseases in your history, but we can do it if you want to check.
• Before you are pregnant, stick to healthy diet, lifestyle and take folic acid. As soon as you miss
your period, come back to see me as soon as possible.
• Regarding your social drinking, it is to stop taking alcohol during pregnancy as it may harm the
baby’s nervous system and defects in development! May associate with fetal alcohol
spectrum disorders.
• Once you are pregnant, in first Antenatal visit we will do thorough physical examination and we
have to calculate estimated date of delivery based on your last menstrual period. Routine blood
test will be done.
• In subsequent visits you need to visit the clinic
• For gestation up to 28 weeks, visit every 4 to 6 weeks,
• For gestation up to to 36 weeks, visit every 2 weeks,
• 36 weeks onwards, weekly until delivery.
• According to schedule, regular antenatal visit is important. On each visit, we have to measure
your weight, measure blood pressure, urine test, and examine your tummy to assess baby's size,
position and listen fetal heart sound and check baby’s movement
• After that mom needs to record fetal movement on everyday. If everything goes fine, you can
do your delivery at term at the hospital under the specialist care to prevent implications.
• do you have any questions?
• can I have sexual intercourse?
• Sexual life is acceptable as normal during pregnancy. But theoretically, sexual intercourse may
initiate labor because it caused chemical release which we call oxytocin. Moreover, sexual
intercourse increases exposure to infection.
• How about the medications? Medications can be used according to prescription. But please
avoid over the counter medications because some medications can affect the fetus.
• What about travel especially airline travel? It is safe up to 28 weeks. Most airlines allow female
to travel up to 28 weeks of gestation but the policies may vary. Some airlines allow up to 35
weeks gestation if mom is healthy. For airline travel, it is important to maintain hydration. Move
your legs avoid sitting prolonged hours. Wear seatbelts to protect against unexpected
turbulence.
Diabetes in Pregnancy
Your next patient in GP practice is a 28-year-old woman, Mary, who is 28-weeks pregnant. She returns
to you for the results of the GTT with 75 grams of oral glucose load done 2 days ago. The plasma
glucose level was 9.2mmol/L (N < 8mmol/L) after 2 hours. She doesn’t have any history of diabetes
before.
Your tasks are to:
• Take history
• Advise the patient of the diagnosis you have made.
• Advise the patient of the management you would give in the remainder of the pregnancy.

History:
• Congratulate for her pregnancy, if planned. Is it your first pregnancy? How are you coping with
it, are u excited? So Mary, 2 days back we did a sweet drink test? This test is done to check the
control of Glucose levels in your body. The results show us that sugar control are not in normal
range. Before going further, Can I ask u some questions first?
• How’s your pregnancy going so far? How was your mid pregnancy ultrasound? Any previous
pregnancies or miscarriages?
• Have you ever been diagnosed with diabetes before?
• Symptoms of DM - Any skin infection e.g. recurrent thrush/candidiasis? Polyuria, do you feel
thirstier? Have you noticed the change in weight before pregnancy? Do you think your tummy
is more distended than what you expect it to be?
• Do you have headache, edema, frothy urine, or blurred vision?
• Any other previous illnesses or surgeries?
• SADMA? Family history of DM?

Physical examination:
• General appearance: edema, jaundice.
• Vital signs: The blood pressure is 120/80 mmHg
• Chest and heart
• Abdomen:
• FH (Uterus is enlarged to the size equivalent to a 28-week pregnancy (symphysis-fundal height =
28 cm).
• Lie
• Presentation- Cephalic presentation,
• Head floating / engaged- head still mobile above the pelvic brim
• FHR-Normal
• Pelvic examination: discharge, spotting/blood, os
• Urine dipstix: No proteinuria.

Diagnosis and management

• Hello, from the tests, it looks like you have developed Pregnancy induced Diabetes.
• GDM generally develops and is diagnosed in the late second or early third trimester of the
pregnancy.
• In addition, I would also organize FBE, HbA1c, urine MCS, USD and CTG.
• I will explain it to you. Normally our glucose levels are well controlled with this means that
during the pregnancy your blood sugar has increased too much. Gestational diabetes is the
result of the hormones produced by placenta.
 • Gestational diabetes increases the mother’s risk and puts the baby at risk as well. Complication:
• Maternal - Polyhydramnios, Pre eclampsia, Placenta Abruption, Increased chance of IOL, CS,
infections
• Fetal - Before birth - Macrosomia (large baby, might require US at 32-34 weeks and possible
Caesarean section if Macrosomia present, IUGR/ IUFD, Obstructive labour
After birth – Jaundice, Impaired lung maturation, Neonatal hypoglycemia.
• Do not worry. You are in safe hands; with good monitoring done by the MDT these risks can
be minimized dramatically. MDT- diabetic physician/endocrinologist, obstetrician, dietitian and
diabetic educator/nurse.
• If your blood sugar remains controlled, you and your baby will not have any of these side
effects. Our main aim is to maintain the BSL to < 7mmol/L by dietary modifications for 2 weeks.
• Also u need to measure the blood glucose thrice a day especially about two hours after a meal. I
would advise you to maintain a diary of your BSL.
• If the BSL is not controlled with the diet for 2 weeks, the diabetic physician might start
Metformin or insulin injection.
• From 32 weeks of pregnancy, we will start doing CTG to monitor the baby.
• Deliver by elective CS if macrosomic (> 4 Kg) (>90th percentile for weight), breech presentation,
or evidence of fetal distress.
• During labour, glucose levels will be monitored and depending on how your glucose levels are,
you might need insulin injections during labor.
• The labour should be at the tertiary hospital and presence of child specialist.

• Will I remain diabetic?

• Usually, the diabetes will resolve after delivery. However, there is an increased chance of
recurrence in succeeding pregnancies and 30% risk of developing DM later in life.
• Hence, we need to organize a follow-up OGTT 6-8 weeks after delivery.
• Fasting Blood sugar and HbA1C 3-yearly.
• 6 R – Recheck, Review, Refer, Reassure, Red flags, Reading material
• Red flags: uterine contractions, leaking of water, etc.

SLE in pregnancy
You are a GP and your next patient is a 24-year-old patient, Laura, who is a diagnosed case of SLE for 5
years. She wants to become pregnant and is seeking your advice.
Tasks:
• Counsel the patient (was on steroids but no longer taking it because she is symptom-free)
• Answer her questions

Outline of approach (not if no history in task)

• How can I help you? I understand that you come here for advise regarding pregnancy and you
are also having SLE, we will talk about it. First please tell me will this be your first pregnancy?
Well, I want to wish you best of luck and hope that everything will be alright.
• Let’s talk about SLE. When was it diagnosed? Who diagnosed it for you? What symptoms did
you have? What treatment was given? Are the symptoms controlled? Which one and what dose
(prednisolone 5mg)? For how long? Did you have any side effects from these medications?
 • How many flare-ups have you had during the past 5 years? When was the last flare up of SLE??
Have you had regular checkups with specialist? When was your last checkup? When was the last
blood test done?
• At the moment do you have any symptoms like skin rash, joint pain, problems with
waterworks? +
• Periods: please tell me about your periods? LMP? Are they regular? Any heavy bleeding or
clots? Partner: are you sexually active? In a stable relationship? Any known previous STIs? Pills:
Any contraception used?
• Previous pregnancy: any miscarriages before. Pap Smear: When was your last pap smear?
• How’s your general health? Any other medical conditions? Any FHx or SLE or recurrent
miscarriages?
• What is your blood group? SADMA?

Explanation
• Since you have got this for 5 years already, I believe that you are already well informed about
the disease. Do you want me to explain what is SLE?
• Lupus is an autoimmune disease that tends to appear in women of childbearing age. The woman
develops antibodies against her own cells, resulting in inflamed tissues in her body. Any part of
the body can be affected, including joints, skin and internal organs. Depending on the areas
affected, and the severity of the symptoms, lupus can be mild or life-threatening.
• There is usually inflammation of different tissues of the body especially the skin, kidneys, and
joints. The exact cause is still not known but certain genes and viruses have been implicated as
stimulants.
• SLE unfortunately cannot be cured, but it can be very well controlled with medications to prevent
flare-ups. The good news is that majority of females with SLE are able to have kids but there are
certain risks that are increased in SLE.
• The best way to have a safe pregnancy is to have lupus well controlled at the time of
conception, so it is in your best interest to work with your healthcare team. It is important that
they should be symptom-free for at least 6 months before conception.
• There are certain risks associated with SLE:
• It is not clear whether pregnancy increases the number of lupus flares or new symptoms of
lupus as 40% have flare-ups however 10% have remissions.
• Maternal risks: 20% develop pre-eclampsia (high BP in pregnancy), (25%) miscarriages (a little
increased risk) Increased incidence of spontaneous abortions and stillbirth → related to lupus
anticoagulant and anti-cardiolipin antibodies
• Fetal risks: IUGR, prematurity (50%), Neonatal lupus syndrome: blood disorders and cardiac
abnormalities in neonate. SLE: small-vessel vasculitis which also deposits in the placenta and
small clots within the placenta > IUGR, prematurity, death
• There is increased rate of miscarriage and premature birth
• During pregnancy, the growing baby is nourished by the placenta. About one third of women
with lupus have antiphospholipid antibodies (lupus anticoagulant and/or anti-cardiolipin
antibody) that may cause blood clots and interfere with the proper functioning of the placenta.
• To prevent the risk of clotting problems or thrombophilia, the specialist might start you on
Aspirin or LMWH that you will need to continue after delivery (especially if anticardiolipin is
positive).
• Low dose Aspirin – given to patient with high risk of anti phospholipid in 2nd trimester. If on
Warfarin, must be stopped before pregnancy.
 • We will consider this pregnancy to be a high-risk pregnancy. You will be managed by the
specialist rheumatologist and a specialist obstetrician throughout the pregnancy. They will
decide upon the best medications for you during pregnancy. It is also important to closely
monitor the growth rate of the baby to make sure that all is well.
• (Also as you are taking methotrexate, I will refer you to ur specialist to change that medicine or I
can liaise with him. Usually, steroids are safe but dose of steroids will be managed. ) (omit
according to scenario)

Advanced age pregnancy and obesity

GP, 42 years female, came to see you because home pregnancy test was positive.
Tasks:
• Take short history for 4 mins
• Physical examination from examiner
• Counsel her for her antenatal care

PEFE
• Vitals – normal
• BMI - 32
• Systemic examination – unremarkable
• UDT – unremarkable
• UPT - positive

• Hello!
• Period : how about your period? When was the last period? What's your period regular? Any
pain or bleeding between your period?
• Pregnancy : have you ever been pregnant before? Any history of miscarriage?
• Pills : Are you on contraception? Which one? For how long?
• Partner : Let me ask you a few sensitive and private questions do you have a stable partner? Do
you practice safe sex? Any chance that you or your partner diagnosed with sexually transmitted
infections?
• Pap Test
• Do you know your blood group and Rh status? How about your immunization status?
• Medical History : Are you generally healthy? Do you have any chronic medical problem? Like
diabetes – how’s your waterwork? Increased thirst? Craving for food?
• Any raise blood pressure, heart disease, kidney problems, joint problems, clotting
problems(DVT)
• Is your partner supportive?
• How’s your everyday diet? BMI?
• SADMA : Do you smoke? How about alcohol? Do you have any medications taking regularly?

Counselling
• Repeat pregnancy test
• If positive – you are going to attend antenatal clinic for regular AN care
• I will put you on folic acid which you need to take until 3 months of pregnancy
• Basic blood tests, blood counts, vitamin levels, liver, kidney functions, infection screening,
Rubella immune status, urine tests
• You will have to be checked for blood glucose as well as you’ve got some symptoms of diabetes.
If diabetes there, we will have to control it with life style changes or medication.

• Another concern, age 42, you can do some pre-natal tests to check for Down’s syndrome as the
chance is a bit higher than younger moms
First trimester
• A blood test, done between 9 and 12 weeks into the pregnancy, looks for hormonal changes
that can suggest there is a problem with the baby’s chromosomes.
• An ultrasound scan, done at 12 to 13 weeks into the pregnancy, measures the thickness of fluid
behind the baby’s neck, called the nuchal translucency for Down Syndrome.
• Non-invasive prenatal testing
• The non-invasive prenatal test (or NIPT) is a newer, very sensitive form of screening for Down
syndrome and other genetic disorders. The test is done after 10 weeks and is more than 99%
accurate for Down syndrome.
• NIPT tests are only done in private clinics and are not covered by Medicare.
2nd trimester
15 -17 weeks-solely blood tests Called Triple test or Quadruple test.
• In high-risk pregnancies, we can offer diagnostic tests: CVS or amniocentesis.
• CVS
• Done ideally at 11-14 weeks.
• A needle will be introduced into your tummy, guided by ultrasound to avoid damage to the fetus
and small portion pf placenta is taken and analyzed for genetic abnormalities
• Amniocentesis
• Done ideally at around 15-18
• A small amount of fluid in bag that surround the baby is taken and analyzed for genetic
abnormalities.
• Other chances of advanced age - Increased chances of miscarriage, ectopic, HTN, GDM, placenta
previa, preterm, increase chance of induction and CS.
• Fetal: Can have Down, Neural tube defect, renal, cardio defects but we are most concerned
about down syndrome
• Reassure the patient!!!!
• I am not telling that all these will occur in you. I am just mentioning the possible risks. We will
try our best to prevent this and your cooperation is needed as well.
• You will have to attend the antenatal clinic as scheduled in a high-risk pregnancy clinic
• At 18 weeks of gestation, we will do the ultrasound imaging to assess baby’s condition and
amount of fluid around the baby and identify placenta position. At 28 weeks, you will need to
have sweet drink test to screen possibility of diabetes during pregnancy if current blood glucose
is normal.
• At 36 weeks, we have to collect the swab from your down below to check the organisms or the
bugs we call it group B streptococcus which can influence treatment on delivery.
• We will work together to have the best outcome!
Counselling for weight management
• What I am concerned is you are having a little bit higher weight than optimal body weight
• Some risks to you and baby
• You – weight will be more increased due to baby, Physical symptoms – joint pains, feeling
discomfort, difficulty to cope with daily life, sleep problems (OSA), Fat - decreased sensitivity to
insulin – risk of DM and hypertension, toxemia in pregnancy
 • Baby – Abnormal growth - smaller growth, larger growth
• Reassure
• You will have to attend the clinic as schedule
• During delivery – need monitoring, risk of obstructed labour, difficulty in providing effective pain
relief, risk of emergency CS
• After delivery – risk of infection (reduced blood supply due to fat tissues), risk of clotting (DVT)
• Refer to dietician, do exercises, Monitor your blood pressure, weight gain, baby wellbeing and
urine checks
• Reassure!!!

Rubella contact
28-year-old schoolteacher presented in your GP clinic concerned she was exposed to an 8-year-old
student who was confirmed to have Rubella infection. She is not sure if she is pregnant or not. LMP
was 10 weeks ago.
Tasks:
• History
• Discuss her concerns
• Answer her concerns

History:
• how are you today? I understand that you are concerned about being exposed to a child with
rubella and being pregnant. How long have you been exposed to this child? Is rubella in child is
confirmed? How?
• Have you had any fever? Rash? Body ache? Sore throat? Any lump or bump around neck? Did
you have any previous vaccination against rubella or any chance you’ve been infected with
rubella before?
• Now please tell me about your periods: When was your LMP? How frequent were your periods?
Are you sexually active? Do you have a stable partner? Did you check UPT?
• Do you have signs of pregnancy? N/V? morning sickness? Tender breasts? Are you in a stage of
having a planned pregnancy?
• Do you have any other systemic illnesses? Are you using folic acid? Meds? Any Medical or
Surgical illness? Pap smear? Blood group? SADMA?

Management
• First pregnancy test.
• Rubella - mild infection caused by a virus usually transmitted by droplet spread. If rubella occurs
in this stage of pregnancy i.e. in first 3 months, then there are high chances that the baby could
also be infected and this can lead to some birth defects called congenital rubella syndrome.
• need to do some investigations to find of your body has power to fight against Rubella.
• Complete damage of baby if mother exposed during the 1st trimester. Further damage can result
to deafness and cataract. Termination should be considered in the first trimester of pregnancy.
• Congenital rubella: Cataract, deafness, developmental delay, irritability, mental retardation,
microcephaly, neurologic (meningoencephalitis). Heart: patent ductus arteriosus, tricuspid
stenosis
• Notes :
• If contact occurs in the second or third trimester, further testing is not necessary – normal
development, just slight risk for ear and eye problem but very less likely.
• Immunity to rubella is not always lifelong and therefore immunity should be checked at booking
visit
• Notify! (if it is her family member)
• Never give MMR during or within 3 months of planning pregnancy. Can cause abortion,
miscarriage, stillbirth, IUGR, fetal infection.))

• So these are the possible results and now, first of all, we are going to run a pregnancy test.
HIV in pregnancy
Nadia, 28 years old, come to you as her GP to review the results of her blood tests done by another GP
at the same clinic. Results HIV antibodies (+) Confirmed, B-HCG (+).
Tasks:
• history
• inform Nadia about her results, do counselling and answer her questions.

• If history is a task – ask 5P and

• risk – Sexual partners, job nature ( work with blood products), needle injuries, blood transfusion,
drug abuse (needle sharing), Tattoos and body piercing
• Symptoms – lumps and bumps, tiredness, respiratory infections, rashes, weight loss, myalgia
• General health, SADMA

Explanation
• Nadia, as my understanding you did both tests, which one do you want to know first?
• I’m sorry Nadia, I carry not good news for you, your HIV is (+). Patient cry---tissue---water---stop
consultation---ask if there is somebody supporting you.
• When patient ask what’s the difference between HIV & AIDS? There’s a virus in your body. The
body produces certain kinds of cells which is the CD4 and fights with the virus. Body will keep
producing the CD4 cells (250 cells) until it finally decreases. When it becomes low in the body,
the body starts to have complications then the patient start to have AIDS.
• To confirm this, we need to do the viral load test and CD4 to see how severe is the condition.
• I’m sorry I need to notify it to the Infectious Disease Department.
• Your pregnancy test is (+)
• What do you want to do about it? How is your feeling about having a baby. If she wants to keep
the baby, what’s the risk?
• The chance of your baby to have the infection is 30% and we can decrease it to 2% by:
• Avoiding vaginal delivery and do Caesarean section (elective)
• Prevent breastfeeding by bottle fed
• By anti-viral medication
• Avoidance of intrapartum invasive fetal interventions
• I need to do:
• Antenatal screening which will also include STD screening: Hepatitis B & C, Syphilis, Chlamydia,
Gonorrhoea
• Antenatal care test: FBE, blood group, liver kidney Function Tests, Blood Sugar Level, Rubella
screening test (IgG and IgM)
• Refer patient to obstetrician and infectious disease consultant
• High risk pregnancy, she should have multidisciplinary team with obstetrician & infectious
disease consultant.
• Chance to have baby vaginally delivered?
• Caesarean section is the safest way for your baby but if you insist by normal vaginal birth, you
need to discuss it with the obstetrician → need to do viral load.
• If the viral load a few days before labour very low, you can have vaginal birth. Caesarean
section offers no further reduction in transmission risk over vaginal delivery if the viral load of
the mother is undetectable.
 • We will do our best not to spread the infection to the baby
• After delivery, the neonatologist will start the baby with medication to decrease the risk of
infection. The newborn is also given a course of antiretroviral for four weeks and should be
exclusively bottle-fed.
• We have to go for a contact tracing –start with the recent partners (your name won’t be
revealed, just with the codes) (for both sexual and drug partners)
• Note: ((Any surgical interference or fetal scalp electrodes cannot be done because the tear will
make the baby at risk of having the infection)

Pregnant woman on lithium

You are a general practitioner. A 24 years old lady, Emma came to ask you for advice. She is on on
lithium for bipolar since the last 2 yrs. She has no symptoms currently and no problem with lithium.
She missed her period thinks she is pregnant. She come to see you regarding that.
Your tasks:
• Take relevant history
• Management

History
• Bipolar symptoms – Mood? Periods of anger? Depressed period? Think like you are superior?
Tearful or sad periods? (Psychiatric history not much needed as it’s already mentioned in the
stem)
• Side effects of lithium - any tremors, weight gain? Poor concentration, weather preference?
• 5 P history (checked pregnancy test?)
• General health, past medical, partner supportive? SADMA
• So, you think you are pregnant. Is it planned? How is your feeling about the pregnancy?

Management
• Pregnancy test. If negative- more hormonal test, female hormones and thyroid
• If positive, Prescribe high dose of folic acid and pregnancy blood tests
• We are going to manage with MDT and frequent follow up at high-risk pregnancy clinic.
• Some medications have effect on fetus
• This lithium – may associated with heart defects, neurological toxicity, thyroid (hypothyroid) and
muscle problems in baby.
• I will refer to you the psychiatrist and obstetrician
• Possibly, he will avoid Lithium in first 3 months of pregnancy when the organs of the baby is
forming. He may use some other drugs (second generation antipsychotics quetiapine,
olanzapine) but they may increase the risk for Diabetes in pregnancy and large babies)
• In 2nd 3 trimester – Lithium (because most effective mood stabilizer and most effective
prophylaxis for relapse in postpartum) dose adjustment needed with frequent monitoring of
lithium level. (Lithium clearance increased), smaller doses with increased frequency will be
needed.
• For baby – 18 weeks ultrasound for structural defects and regular ultrasound, other necessary
investigations for wellbeing
 • Very important to come and visit regularly as scheduled because in pregnancy – hormone levels
and kidney functions are changing, so dose adjustment is really important!
• During birth, monitor Lithium level throughout labour (blood levels changes) (some may suggest
to stop Lithium 1-2 days before delivery according to the condition)
• After birth - avoid breast feeding, Lithium presents in milk or use other drugs.
• Reassure - many patients with this condition have successful pregnancy and we will work it out
together for the best outcome with MDT approach
• Advice – Important to avoid sleep deprivation during pregnancy and after delivery (major risk
for relapse)
• Reading material

Anaemia in pregnancy
You are a general practitioner. You are seeing a 30 weeks pregnant lady, Amanda, come to GP for
blood results showing microcytic hypochomic anaemia. Hb – 10g/dl
Tasks:
• -interpretation of results to the patient
• -History
• Management

History
• How do you do? Planned pregnancy? Congratulations for the pregnancy.
• Explain – Your blood result is showing low haemoglobin level which means anaemia.
Haemoglobin is a protein in RBC that carries oxygen and it is red in color. When it is reduced, the
patient looks pale.
• So let me ask you some questions first before we talk about it.
• Symptoms of anaemia – SOB? Racing of heart? Tiredness?
• Pregnancy questions – How is your pregnancy going so far? Did you take folic acid? 18 week
ultrasound? Regular AN care? Blood results? Number of fetus? Placenta position? Tummy pain?
Bleeding? Water leakage? Is the baby kicking? Past pregnancies? How old are the kids now?
Mode of delivery? Any complication especially like massive bleeding?
• Causes – diet usual diet? Any preference? Stool color changes? How was your period? Regular?
Amount? How many days of bleeding? Any blood disease run in the family or in you? What is
your racial origin? Have you travelled recently? (hookworm infestation)
• Medical and surgical, SADMA

PEFE
• General appearance? Vitals? Pallor? Jaundice? Beefy tongue? Angular stomatitis?
• CVS – esp haemic murmur?
• Obstetric exam

Explanation
• Anaemia has some risk to the baby and mom. For mom, it may result in reduced oxygen supply
to the organs especially heart which may result in heart failure. For baby, it may result in
reduced oxygen supply to the baby (hypoxia), Growth restriction and fetal loss in very few cases.
• Reassure!
 • First of all, we have to identify the underlying cause. Mostly the cause is iron deficiency which is
a main raw material for Hb. It could also be minor type of Thalassaemia which is a blood disease
runs in the families. So We will run an iron profile first. If iron level is reduced, it is confirmed as
iron deficiency anaemia. In your case, it is most likely because of short interval between babies.
Generally, the interval between babies should be 2 years to make sure that mom is fit enough
for the next pregnancy. Short interval causes increased demands which may leads to anaemia.
• Also being a vegetarian may lead to reduced intake of iron resulting in anaemia.
• So I will review you again with the blood result. If iron level is normal, we may proceed further
investigations for thalassemia.
• If iron deficiency, you will need iron supplements. You may notice dark stool and constipation as
side effects. Are you taking milk or eggs? (if yes, suggest to eat more with vitamin C, and green
leafy vegetables and to avoid tea, coffee).
• Reassure – at this time, the baby is doing good and you don’t have any symptoms. So we can
expect the best outcome.

Thalassaemia
You are a general practitioner. A 25 years old lady with 10 weeks pregnancy visited to your clinic for
antenatal check-up. All normal except low HB (90 g/l), blood film shows HMA. Iron study is normal.
Tasks :
• History
• Dx
• Management

• History is the same as prev case but ask about partner’s racial origin as well for the possibility
of thalassaemia in the baby

• Most likely it is a minor thalassaemia . It is a gene defect common in Mediterranean countries.

RBC has two parts, heme and globin. This is a defect in globin parts which results in abnormal
haemoglobins which cannot function properly to carry oxygen. So, it results in anaemia.
• You just have mild anaemia. You don’t have any other serious signs and symptoms. So you may
be a carrier of the disease which means only half of the genes is affected. You received it from
your mom or dad. Patient with carrier stage means they don’t have any signs and symptoms;
the condition is found accidentally.
• To confirm the condition, we need to do Hb electrophoresis. (your blood sample will be run in
electric current to differentiate components of normal and abnormal Hb). Normally, there are
less than 2% of abnormal Hb. In thalassaemia, it is increased.
• For your case, no further treatment is necessary. My concern is about the fetus because it is a
familial disease. So, I will refer you to gene specialist.
• I will explain you roughly.
• If your partner is disease free. (Draw a pic), no disease, 50% will be carriers.
• If your partner is disease carrier like you. (Draw a pic) 25% chance of disease, 50% chance of
carrier and 25% chance of disease free in each offspring.
• Your pregnancy is early. So after confirmation of the condition, we can have the prenatal
diagnosis by doing amniocentesis (fluid around the baby is taken and examined) or Chorionic
villus sampling in which a piece of placenta tissue is taken and examined.
 • So for the moment, we will do Hb electrophoresis. After knowing the condition, you and your
partner may need to go to genetic specialist.

Murmur in pregnancy
You are a GP. A 32-year-old, Samantha visited to you. She is 20- week pregnant lady and came in due
to shortness of breathing.
Tasks:
• History
• Physical examination
• Diagnosis and management

History
• SOB - 1st time? Any consultation for that? Any tests done? Any Tx before?
• Details - Since when? Started suddenly or gradually? Any trigger event before start like cold,
change in medication, etc? progressive? At rest or with activities? With activities – your daily
activities or strenuous activities? (if occur with daily minimal activities – needs treatment)
• Other symptoms: fever, cough, noisy breathing, chest pain? Racing of heartbeat?
• DDx - Can you sleep flat? How many pillows? Any swelling of your ankles? Any Hx of medical
d/s like heart problem, asthma, bld d/s? Looking pale? Any regular medications? Any history
of diabetes or thyroid problems? Any history of rheumatic fever with rashes and join pain
following sore throat? How was it treated?
• social- with whom do you live? support at home? Mood?
• 5 P questions – current pregnancy? Is it your first pregnancy? Planned? Antenatal checks? USG?
Attending clinic regularly?
• Partner – supportive?
• How was your period? How many days of bleeding? Any heavy bleeding?
• Recent travel
• Family history of heart diseases
• SADMA

PEFE
• General appearance – SOB, cyanosis, pallor, J
• Vital signs
• CVS: JVP raised or not? any visible pulsation, apex beat – displaced, tapping, heaving?
Parasternal heave, palpable P2, thrills, murmur & its features (MS – low pitched, rumbling,
diastolic murmur, opening snap and best heard with the patient in left lateral position)
• Respiration – crepitations?
• Abdomen – ascites and organomegaly
• Legs oedema
• Obstetric examination
• ECG, UDT

Explanation
• According to your history and PE, I suspect narrowing of a heart valve what we called mitral
valve stenosis. Mitral valve is between the upper and lower chamber of the left side of the
heart.
 • Valve Narrow – cannot open fully – disturbing with blood flow. Before pregnancy, there were no
symptoms but when pregnant – there is increased in blood volume – increased workload on the
heart – SOB resulted
• Many causes but commonly caused by rheumatic fever complicated into rheumatic heart
disease
• I will refer you to Cardiologist for further assessment.
• You will need ECG and echo to confirm Dx and assess the severity and heart function. Other
tests s/a FBC, UEC, BSL, Lipid, Urine, etc
• Sometimes, it may be complicated as heart failure so you will need to be referred to high risk
pregnancy clinic.
• Probably, you won’t need any specific treatment at the moment except watchful monitoring
because your symptoms only appear with strenuous activities. The treatment for heart failure
with medications will be commenced when these symptoms like SOB, racing of heart occur with
your daily normal activities or at rest.
• If severe heart failure, we can use same drugs (beta-blocker, digoxin, diuretics) as non-pregnant
women except ACEI. Referral to the specialist for that.
• If time still left, talk about delivery
• Most women - easy spontaneous labor vaginally. no indication to induce labor.
• During labor, on your side or well-propped up to avoid compression of the major vessels (aorta),
marked fall in BP. If delay in 2nd stage, will assist with instruments (forceps/vacuum).
• If required to stimulate womb contraction, we will use the medication oxytocin
• There will be close monitoring during the delivery and after.
• Do you have any questions?
• Reassure

Twin pregnancy
You are a general practitioner. A 25 years old Emma came to your surgery for her USG results. She is
pregnant for 18 weeks and did her regular 18-week USG. The result is showing dichorionic diamniotic
twins, head presentation. No other abnormalities.
Your tasks:
• Explain the test result to mom
• Further history taking
• Explain significance of multiple pregnancy

Approach
• Greetings. 1st pregnancy? How do you expect about the USG result? How many children you
are planning to have? How will you feel if you are going to get two at once? Congrats! You have
a twin pregnancy.
• Draw a picture. Twin – two babies in the womb, dichorionic – in two separate placentae and
diamniotic – in two separate water bags.
• Everything’s normal. No fibroid, placenta location and presentation also normal.
• Let me ask you a few questions. Is the pregnancy planned? Have you taken folic acid? Any
excessive nausea and vomiting? Bleeding? Watery discharge? Any tummy pain? Headache?
Visual disturbance?
• Causes – family history, fertility drugs (clomiphene, IVF)
• AN care – can you recall the blood tests in AN visit? Any abnormality? Balanced diet?
 • How is your pregnancy going so far?
• SADMA social

Explanation
• Emma, you are going to have two babies now You might be very happy. The twin babies are
really cute together. But what I am concerned is the multiple pregnancy has slight increase risk
to both mom and baby. Let’s talk about them and how to prevent it.
• Risk for mom
• During pregnancy –
• There is increased demand because there are two babies, in some condition, there is increased
chance of anaemia too.
• Increased hormones may also cause excessive morning sickness in mom.
• Slight increase in risk of medical problems in mom than single baby for eg high blood pressure,
high blood sugar level
• 2 babies in one womb, more pressure effect on birth canal – tortuous veins (varicose veins) in
the legs
• 2 babies – there is more fluid around the baby than single, increased chance of rupture of
membrane before term or onset of labour
• Chance of abnormal presentation, cord prolapse (the cord is coming out before the baby and
risk of reduced blood supply to the baby)
• During delivery –
• Mode of delivery depends on first twin
• 1st twin – head presentation – vaginal delivery possible
• If other positions – Caesarean section
• Post-delivery –
• Because of overstretched womb, there is increased risk of bleeding during and as soon as after
delivery
• Risk for fetus –
• During pregnancy
• Increased risk of membrane rupture – increased risk of preterm baby which may associated with
low birth weight, infections and breathing problems
• So Emma, I am just mentioning the possible risks to mom and baby. It is not necessarily meaning
that those will occur in you
• We will work it out together to have the best outcome. Many twins pregnancies had the
successful deliveries and it’s a blessing to have two kids at once.

• (note: twin to twin transfusion if monochorionic)

• Management (not in this case)

• We are going to take care of you with joint care to prevent the risks.
• Obstetrician – will look after you and babies. Me as a GP also will take care of the wellbeing of
you and the babies. You will need a more frequent visits. On each visit, we will do physical
examination and some tests.
• 28 weeks – sweet drink test, USG – welling, growth, size, position
• 30 weeks and afterwards – 2 weekly USG until delivery (for twin to twin transfusion – imbalance
of nutrition between the babies) and also check the size, presentation, liquor, placenta.
 • 36 weeks – vaginal swab for GBS
• Throughout the pregnancy – Mom need to continue a healthy diet to keep up increased
demand, continue vitamins.
• Avoid strenuous exercises
• Delivery
• If everything’s fine, delivery at 37 completed week
• Preferred Mode of delivery ? – VD possible if conditions favorable.
• VD is possible if both twins are adequate size and head presentations
• If 1st twin- no head presentation –CS
• We will try as much as we can to fulfil patient’s choice. But not every case is successful – may
have emergency LSCS
• In Australia, elective CS is usually done at 37 or 38 week because it is considered to be safer for
both mom and baby
• Delivery should be at tertiary hospital under obstetrician’s care and babies should be taken care
by the neonatologist.
• I will refer you to obstetrician now for the further discussion. The obstetrician may prescribe
tocolytics and steroids in your late pregnancy to prolong the pregnancy and to speed up lungs
maturity.

Transverse Lie
You are an HMO working at a district hospital and a 38-weeks multigravida, Olive, who lives 80 km
from the tertiary hospital was found that the baby had a transverse lie.
Tasks:
• Relevant history
• Physical Examination
• Management

Outline of approach
• how are you today? Is it a planned one? How your pregnancy so far? Did you have regular
antenatal checkups? How were the blood tests? What about the mid pregnancy USD? Do you
remember what the doctor said about the baby and placenta (Single baby and position of
placenta)? Sweet drink test? Did you have a low vaginal swab done (GBS)?
• Any abdominal pain/contractions or water leakage? Any vaginal bleeding? Do you feel the
baby is kicking? Are you maintaining a kick chart?
• Do you know your blood group? Do you feel your tummy is more distended than it should be?
Did you have any infection during pregnancy?
• How many children did you have? What type of delivery ? Were they big babies?
Complications?
• How is your general health? Ever been diagnosed with fibroids or any uterine problems? FHx of
malpresentations? SADMA?

Physical Examination
• General appearance
• Vital signs
• Chest and Lungs
 • Abdomen: broad transverse uterus with a firm ballot able round head in one iliac fossa and a
softer mass in the other, assess (FH does not correspond to gestational, uterus is ovoid, fundus
is empty and head lies in one of the flanks, no tenderness, FHT normal)
• If fundal height corresponds with age (to rule out polyhydramnios – large for date).
• Pelvic: Inspection and Speculum: discharge, blood, cervical os, nitrazine test,
• UDT, Blood sugar

Explanation
• I found out from the notes that your baby’s position is different from the expected. Draw a
picture and explain transverse lie.
• There are several reasons for that:
• Placenta previa (placenta lying in the way of the baby and prevents the baby from turning to
normal position). We will need to do an ultrasound to rule out this condition and – imp
• Small pelvis, but it your case it is least likely because of previous pregnancy and delivery.
• Polyhydramnios (or increased amniotic fluid around the baby) which is also another cause of this
position.
• The commonest reason is a relatively large and lax uterus after previous pregnancies. This cause
is most likely in your case.
• For now, I will organize an ultrasound and CTG for you and arrange for an obstetric assessment.
• There are two options to manage your pregnancy. Whichever you choose, you will need to stay
at the hospital until delivery:
• (to examiner: Do we have a cesarean section unit in this hospital?) If not, then transfer to
tertiary hospital because labor may commence soon.
• Why do I have to stay in the hospital? The reason for that is if labor starts and the baby has
transverse lie, it can quickly progress to obstructed labor which can lead to uterine rupture.
• Another risk is cord prolapse (cord can slip into vagina) after membranes rupture and it is a life-
threatening condition for the baby.
• Let me reassure you that you and your baby will be closely monitored by the specialist. I will call
the ambulance for transfer. We are quite far from a hospital with facilities and you are at term
and you have options:
• Firstly, you need obstetric assessment and when placenta previa is excluded an obstetrician can
try to rotate the baby to normal position. We call this external cephalic version. If it is successful
and your cervix is favorable, OB will rupture the membrane and you will go to normal vaginal
delivery. External cephalic version is quite a safe procedure. However, approximately 0.5%
requires immediate cesarean section due to fetal distress or vaginal bleeding (abruption).
• 2nd option is of elective cesarean delivery. Whatever you decide, we are here to help you
Recurrent Miscarriage
You are a GP. A 30 years old lady who had recurrent miscarriages came to visit you. Now she wants to
get pregnant again and needs your advice about next pregnancy.
Tasks:
• History taking
• Explain about further management plan

History
• Greetings
• I am sorry to hear that. I understand that you are having a difficult time. How are you coping?
• Let me ask you some questions to know the details. Some questions might be private and
sensitive to you. Are you ok to proceed?
• Miscarriages: How many times? Ho far apart? When was the first time? When was the last time?
Did they have similar nature? What exactly happened each time? Can you recall the age of
pregnancy when it happened? Did you have procedure for it? Any bleeding or fever after
procedure?
• Causes –
• Injury – any injuries before it happened? Did you take folic acid? Any abnormal AN tests?
• Infection – Rubella immunization status? Any pets at home? Exposed to pets?
• Blood group – you? Your partner’s?
• Medical problems – DM, HT, Clotting problems, rash, joint pain, thyroid
• Family history
• Any surgery done down below?
• Other 5 P questions
• SADMA
Explanation
• I am so sorry. The history of multiple miscarriages makes you liable to happen again like 50%.
But you still have 50% chance of having a successful pregnancy.
• Many reasons – infection, medical diseases in mom, trauma, blood group problems and
chromosome abnormality lead to this.
• We will find out the cause by doing some investigations including: Infection screening,
thrombophilia screening, RFT, LFT, blood sugar, urine tests and USG maybe genetic testing.
• Some advice – healthy diet, stay away from pets, higher dose of folic acid
• I would refer you to the gene specialist to have a consultation about possible genetic conditions.
We will give you a joint care including me and obstetrician for the best outcome possible.

GBS positive in urine

You are a GP. 14 weeks pregnant lady visited to your GP for the antenatal visit. The Blood
investigations show
• Hb 11.2 (normal 11.5)
•
GBS positive in MCS 105
• HBs antibody positive
• HIV negative
• Nuchal translucency 12 (normal)
• Tasks:
• Take history for 3 mins
• Explain the investigations
• Management

Outline of approach (need more details)

• In history, mainly focus on urinary infection symptoms for GBS (fever, any burning sensation
while passing urine, smelly urine, color changes in urine, tummy pain)
• Pregnancy antenatal questions as usual
• Diet and supplements for anaemia
• Explain the Invx one by one
• GBS – this count is significant but we have to check this again with the labia separated. If the
count still the same, we gonna give you oral antibiotics for 5 days and the test repeated 7-10
days after antibiotics and the treatment will be repeated if necessary. Also intrapartum IV
antibiotics may be necessary which is antibiotics through the veins during the delivery because it
can lead to serious infection in the babies.
• Advice about diet for anaemia (eat more green leafy vegetables and meat, avoid tea and coffee)

HSV in pregnancy
You are a GP. You are going to see 27 years old woman with recurrent vulvar ulcer. She is 8 weeks
pregnant
Tasks:
• take history for 5 mins
• Pic from examiner
• dx and ddx
• management
 •
History
• CONFIDENTIALITY!!!
• ulcer - When first noticed, Onset, Duration, Progression – increase in size, predisposing events,
Aggravating/ Relieving factors, is it similar to previous attack?
• Previous attacks – how many before? When was the first attack? How long did it last? How did it
relieve?
• Associated symptoms: fever? discharge - from where? Any swelling/ growths/ ulcers/bleeding?
• Any pain? What about the previous attacks? Any pain while passing urine? Any itchiness?
• Any trauma? Any allergy history? New brands of skin products or underwear?
• 5 P history, partners in details
• Partners –are you sexually active? Stable partner? How long? all partners in last 6mnths:
• How many?
• any partner STIs ?
• condom use
• Type of the intercourse? (oral, anal, vaginal)
• Any stress at work or home? Occupation?
• Pregnancy and antenatal questions (infection screening)
• Past medical- any underlying medical condition I should be aware of? Any medications?
(immunosuppresants)
• surgical history - Past history of genitourinary disease, previous STIs? Ever checked before?
• SADMA

Explain
• There are many causes leading to these recurrent ulcers. But among them, most likely the
condition is HSV infection. Most of the cases of recurrent genital ulcers are caused by type 2 of
this virus.
• It’s a sexually transmitted infection but sometimes it’s asymptomatic in males.
• Once the patient is infected with that virus, it stays in the nerves of the body for life long. So the
relief of the symptoms doesn’t necessarily means the virus is dead. It stays in the nerves and can
be reactivated in some circumstances when there is stress, infections, pregnancy or whenever
the patient has low immunity.
• Other causes would include other STI like syphilis, chlamydia or gonorrhea but less likely in your
case.
• Management – I will examine you and take the swab for HSV test to confirm the diagnosis.
 • I will give you a numbing gel to apply now (if any pain), Will refer you to specialist if not
tolerable (oral antiviral is not contraindicated but not recommended by RACGP)
• After 36 weeks onwards, you’ll be on suppressive antiviral therapy.
• When in labour, when there is active lesions – we will proceed to CS.
• If you have any pain, you can also try sitz bath to relieve pain.
• It is advisable to avoid sexual intercourse during treatment. Also wear loose cotton underwear.
• Also, I would like to arrange the screening for these in your current partner.
• Follow up after the results
• Once you resume the sexual life, it is recommended to practice safe sex.
• If recurrences six or more in a year, you may need a long-term suppression therapy with
antiviral.
• Reading materials.

NIPT
You are a GP. 11-weeks pregnant lady coming to discuss about NIPT.
Tasks:
- Take history
- NIPT will appear at the end of 5 mins
- Explain the result to the patient

• Hello! I need to ask you a few questions as a routine. how long have you been here in Australia?
May I know your ethnic origin? How about your husband? When will you be pregnant?
• Period : how about your period? When was the last period?
• Pregnancy : have you ever been pregnant before? Any history of miscarriage?
• Partner : Let me ask you a few sensitive and private questions do you have a stable partner? Do
you practice safe sex? Any chance that you or your partner diagnosed with sexually transmitted
infections?
• Pap Test : In Australia we recommend cervical screening test? Have you ever done your pap
test? When was your last Pap test? What was the result?
• Do you know your blood group and Rh status? How about your immunization status? have you
ever exposed to a child with acute infection with rubella or chickenpox recently?
• Medical History : Are you generally healthy? Do you have any chronic medical problem? Like
diabetes, raised blood pressure, heart disease, kidney problems, joint problems, clotting
problems(DVT)
• Social : With whom do you live? Is your partner supportive? Any blood relation between you
and your partner? What do you do for a living? Any genetic condition in you or your partner or
in your relatives?
• SADMA : Do you smoke? How about alcohol? Do you have any medications taking regularly?

Explanation
• Noninvasive prenatal testing (NIPT) is a method of determining the risk that the fetus will be
born with certain genetic abnormalities. This testing analyzes small fragments of DNA that are
circulating in your blood.
• During pregnancy, the mother’s bloodstream contains a mix of free DNA that comes from her
cells and cells from the placenta. The placenta is tissue in the womb that links the fetus and the
mother’s blood supply. These cells are shed into the mother’s bloodstream throughout
pregnancy. The DNA in placental cells is usually identical to the DNA of the fetus. Analyzing
those free DNA from the placenta provides an opportunity for early detection of certain genetic
abnormalities without harming the fetus.
• NIPT is a screening test, which means that it will not give a definitive answer about whether or
not a fetus has a genetic condition. The test can only estimate whether the risk of having certain
conditions is increased or decreased.
• It is often used to look for chromosomal disorders that are caused by the presence of an extra or
missing copy (aneuploidy) of a chromosome which is a piece of genetic information. Different
chromosome disorders lead to different genetic conditions.
• So, let’s see your results together. First it says that it’s likely to be a female baby as the
components of chromosome are different between male and female babies.
• Overall, the baby is of low risk for genetic conditions. And the fetal fraction is the portion of the
placental chromosome in the sample, and it should be at least 4% for an accurate result, yours is
8.8% so it’s good.
• The risk before the test is calculated upon your age, age of pregnancy and/or general
population. Risk after test is depending your sample specifically for you but we still have other
factors like family history and USG findings to consider for a more specific prediction.
• So we checked for Down syndrome (trisomy 21, caused by an extra chromosome on number
21), trisomy 18 (caused by an extra chromosome 18) associated with Edwards syndrome often
results in stillbirth or early death of the baby, trisomy 13 (caused by an extra chromosome 13)
associated with Patau syndrome often results in severe intellectual disability and physical
abnormalities, and extra or missing copies of the sex chromosomes, X and Y which may prevents
the normal development in various parts of the body including sexual organs.
 • 22q11.2 deletion is for DiGeorge syndrome which often associates with heart, development and
learning problems.
• So, the good news is your baby is low risk in all these conditions, so these are highly unlikely in
your baby.
• But you still need to attend the ANC regularly as scheduled for monitoring the baby, eat healthy
and do the other screenings as blood sugar and bug tests as scheduled.
• Any questions?

Pyelonephritis
You are a GP. 15 weeks (about 3 and a half months) pregnant woman comes to your primary care
clinic attached to hospital with right abdominal pain.
Take history for 5 mins
PEFE card
Tell the Dx
Discuss the management

PEFE card
Vitals – temp – 38.6, BP -120/80mmHg, Pulse – 80 bpm, Oxygen – 98%
General appearance – unwell patient
Abdominal examination – right renal angle tenderness positive, others – unremarkable
Urine dipstick - Nitrites & leucocytes

• Stability, painkillers
• Pain questions - When did it start? Can you show me with one finger where is the pain? Has it
always been there or did it start somewhere else? Can you describe the type of pain? Does the
pain travel anywhere else? Can you recall any precipitating factors? How bad is the pain on a
scale of 1-10? Does anything make it better or worse? Is it the first episode?
• DDx – appendicitis – fever, nausea, vomiting? PID – any discharge from down below? UTI – any
problem with waterwork? Any burning sensation? Color change or smelly urine? Colitis – any
changes in poo?
• Pregnancy questions – how is your pregnancy going so far? Regular AN care? Any abnormal
test?
• How’s your general health?

• DDx- Pyelonphritis (provisional), Cystitis, stones in the kidney and urinary tract.
• Pyelonephritis is the infection in your kidney ascended from lower part of the urine tract and
the infection in the urine tract is quite common in pregnancy.
• If not treated – infection can spread through blood – septicaemia or damage the kidney
• Rx - admission, specialist will check, do the blood tests including blood culture, kidney functions
and urine culture, USG
• Antibiotics through veins (Amocixillin and Gentamicin/ Ampicillin and Gentamicin) and change
according to culture results. IV will be at least 48 hours and maybe changed to oral later.
• And prophylaxis antibiotics after treatment or monthly urine culture should be repeated until
delivery and IV AB during delivery will be done.
Itchy rash in pregnancy
You are a GP. A pregnant lady comes in 35 weeks (about 8 months) of
gestation complaining of an itch.
• take history,
• give diagnosis and
• management .

• Which part ? Duration? Is it the first time? Any rash? Discharge ? open sores ? painful?
hot to touch? Any anywhere else on your body?
• Changed any cream or medication?
• Any contact history? Any fever?
• Any changes in urine and bowels? Any nausea and vomiting?
• Pregnancy and antenatal care history
• Any history of allergy, eczema, asthma in you or your family?

• Dx - pruritic urticarial papules and plaques of pregnancy rash which is a common skin
condition. (also called polymorphic eruption of pregnancy)
• This type of rash usually starts in stretch marks on the abdomen and spreads to the legs
and chest.
• It causes itchy, red, hive-like bumps to form in the creases of stretch marks, and the rash
can develop into larger red, swollen patches.
• Pruritic urticarial papules and plaques of pregnancy (PUPPP) often develop in the third
trimester of pregnancy. In most cases, the rash resolves within 15 days of giving birth.
• Mx – topical steriod

Early Pregnancy Complications

Molar pregnancy
Your next patient in the emergency department is a 24-year-old Vivian with vaginal bleeding at about
the 12th week of her second pregnancy. She feels excessively nauseated and suffers from a lot of
vomiting and she feels that her abdomen has become considerably larger and much quicker than in
her first pregnancy.
Task:
• History, PEFE from examiner
• Counsel patient regarding current and future management

History:
• Is my patient hemodynamically stable? How do you feel at the moment? Do you feel dizzy or do
you feel like lying down? I can see from the notes that you’ve had vomiting? Can you please tell
me more about it? Color of vomiting, are you able to keep anything down? Any diarrhoea.
• Any bleeding or discharge from down below? - grape like vesicles. Any tummy pain? SORT SARA
(Pain will be all over the tummy) Pain killer for her after enquiring. Did the bleeding start after
 pain? Severity of bleeding- Number of pads. Clots. Passage of tissue like material? Do you know
your and your husbands blood group?
• Pregnancy: How do you confirm the pregnancy? Had you had all the antenatal blood checks?
Another pregnancy or miscarriage. Any history of trauma?
• Contraception Used before. PAP smear. SAD. Enough support at home. Family history of any
miscarriage.

Physical Examination:
• GA- pallor, BMI, any signs of dehydration
• Vitals
• Abdomen: Any scar, swelling, bruise, Any mass, tenderness, Bowel sounds
• Pelvic
• Any grape like vesicle present
• S- os closed?
• B-no CMT, uterine size is 16 week , No tenderness, Office based tests
• BSL, no need of pregnancy testing

Diagnosis & Management:

• Dear Jessica, do want anybody to be with you at this moment. From the history and
examination, I am feeling sorry to tell you that your pregnancy is not viable as it is a molar
pregnancy. Have you heard about that? I am sorry for your loss. In molar pregnancy, the
placenta and the baby is replaced by grape like vesicles. The exact cause is unknown., but its
consider to be genetic disorder where.
• I understand that it might be shocking for you. This condition can be a serious problem. Is it
alright for me to continue? Molar pregnancy is rare (1 in 1400) occurs when the fetus is not able
to form completely.
• As you know, in a normal pregnancy, the sperm and the egg fuse to form the fetus. This fetus
carries equal genetic material from mother and father.
• There are 2 types of molar pregnancies:
• A 'complete mole'. The tumour has completely replaced the placenta, no fetus can be found.
Spermatozoon enters an ovum that has lost its nucleus (complete mole-46XX).
• A 'partial mole'. This is where a fetus is present, but is unable to survive, and is often absorbed
into the vesicles that continue to multiply. The ovum is fertilized by 2 sperms at the same time
(incomplete mole-69-XXX).
• The resulting tissue lacks maternal genes, therefore only the placenta is formed. This placenta
grows and invades/erodes the lining of the womb which causes bleeding. The placenta is also
responsible for the production of a hormone called beta-hcg that gives the usual symptoms of
pregnancy such as nausea, vomiting, and breast tenderness.
• In a molar pregnancy, the placenta is abnormal and grows massively and it contains fluid-filled
sacs or cysts that replace the fetus.
• Those sacs sometimes travels within the circulation sometimes reaching the lungs, brain, bones.
We then label it as invasive mole or choriocarcinoma (1 in 20) that can carry serious
consequences.
• At the moment, I need to send you to the hospital urgently. Before you go, I will start fluid
through veins.
• They will admit you and call the obstetrician. This pregnancy needs to be removed either by
dilatation and evacuation or by suction curettage under oxytocin drip (Avoid oxytocic until after
 completion of evacuation as may increase the risk of embolization. It will be done under general
anesthesia (they will put you into sleep) so you will not feel any pain.
• We will need to do serial hcg monitoring every week until it touches normal level and stays
normal for the next 3 samples and also we will do monitoring of HCG monthly for one year. If
it remains elevated or persistently highly, we will need to check for the spread of the disease by
doing CT scans of the chest and abdomen. If anything is detected, you will be referred to the
cancer specialist.
• We will also do serial USD every 2 weeks. After the procedure, they might decide to give you a
form of chemotherapy (Methotrexate) as some cells from the mole can reach the circulation.
• Once the treatment is completed and the B-Hcg comes down to be normal, you need to avoid
pregnancy for 1 year because in pregnancy as it interferes with b-hCG monitoring.
• I will refer you to the counselor because you need a lot of emotional support at this time. It is
normal to be upset after losing a pregnancy.

Bleeding PV
You are a HMO in the hospital. 27 years old lady, Lola, complains of vaginal bleeding.
Tasks:
• History
• PEFE
• Dx, Ddx

• Stabilize the patient –take blood for cross matching and reserve 6 units
• two wide bore cannula, bolus of NS and run NS,
• History – bleeding – when? How much? Color? Clots? Amount? Dizzy? SOB?
• 5 P including pregnancy test
• DDx – tissue or vesicles down below, Bleeding disorders, recent trauma?
• Tummy pain?
• SADMA and blood group?

• PEFE – Vitals, abdominal, and Inspection – blood, Sterile speculum exam –status of os, tissue,
Bimanual – tenderness, uterus size
• Remove the tissues with forceps if present
• Sympathy
• Most likely, partial miscarriage that means you have lost your fetus and passing some fetal
tissues , threatened miscarriage but unlikely since I’ve seen the tissues in your down below,
molar pregnancy, bleeding disorders, ectopic pregnancy where the pregnancy is other place and
not in the womb but unlikely
• Notes : some cases, tissue at os not given, So we will need to run a few tests including FBE, USG,
BHCG, coagulation profile.

Ectopic pregnancy
You are a HMO at ED. 26 years old, Elle, is coming to you with abdominal pain.
Your tasks:
• History
 • Ask PE from examiner
• Ask investigations from the examiner
• Diagnosis and differentials to the patient

• Approach
• Abdominal pain – severity ? Very severe – stability?
• Pain questions – Site, onset, character, radiation, association, time course,
exacerbating/relieving factors, severity?
• Is it the first time?
• DDx – appendicitis – fever, nausea, vomiting? PID – any discharge from down below? UTI –
any problem with waterwork? Colitis – any changes in poo? Ectopic – any bleeding from down
below?
• 5P questions –period? How many days of bleeding? Regular? LMP?
• Partner ? Stable? STI?
• Pills – contraception?
• Pregnancy – pregnant before? Nausea, vomiting, breast tenderness?
• Pap smear
• SADMA

• PEFE – general appearance and vital signs

• Abdominal examination – inspection, palpation, Rovising’s sign, Mc Burney point, Psoas,
Obturator test, auscultation
• Pelvic examination – inspection- bleeding, discharge, speculum – cervical and vaginal wall, BME
–uterus size, cervical excitation pain, tenderness
• UCG, UDT

• Investigations
• Blood – BhCG
• Imaging – transvaginal ultrasound – uterus empty or not, ectopic focus, ovaries and tubes
• Laparoscopy (diagnostic and therapeutic)

• Explanation – Draw a picture. Most probably you are pregnant but it is located outside the
womb which is not the same as the usual pregnancy, ectopic pregnancy.
• This is the womb. Normally, successful egg implants somewhere inside the womb. In ectopic – it
implants outside the womb. In your case, I found it at ………… At there, the space is limited as the
fertilized egg will grow bigger, causing tension – pain and finally, the tube may ruptured –
resulting in massive bleeding and can be very serious. So you need to be admitted.
• Other possibilities – infections in female tract (PID), abortion, normal pregnancy, appendicitis –
but less likely

Hyperemesis gravidarum
You are a HMO at hospital. 26 years old female, Laura, had nausea n excessive vomiting since
morning. her LMP was 8 weeks ago.
• Task
• History
• PEFE
 • Dx and DDx
History:
• hemodynamically stable? How do you feel at the moment? Do you feel dizzy or do you feel like
lying down?
• How was your pregnancy confirmed? Is it planned?
• I can see from the notes that you’ve had vomiting? Can you please tell me more about it? Since
when?
• Color of vomiting, are you able to keep anything down? Does the vomitus go away?
• Any bleeding or discharge from down below? - grape like vesicles?([Link]) Any fever? Any
tummy pain? (pyelonephritis, appendicitis) (ask details if pain is there). Any diarrhoea? (GE)
Any burning sensation while passing urine? Smelly urine? (UTI), Any headache, fits? (SOL)
• Pregnancy:Is it your first pregnancy? How do you confirm the pregnancy? Had you had all the
antenatal blood checks? What about USG?
• Contraception Used before. PAP smear. SAD. Enough support at home. Family history of
twins!.Any assisted conception?

• Physical Examination:
• GA- pallor, any signs of dehydration?
• Vitals
• Abdomen: Any scar, swelling, bruise, Any mass, tenderness, Bowel sounds, Mc Burney’s point
and Rovsing’s sign for appendicitis (esp if pain present), Renal angle tenderness
• Pelvic
• Any grape like vesicle present
• S- os closed?
• B-no CMT, uterine size is 12 weeks, no tenderness, Office based tests
• BSL, UDT – ketone +++, UPT

Explanation
• The condition, most probably, Hyperemesis gravidarum, due to unstable hormones in early
pregnancy, starts at 4-6 weeks and resolves at 20 weeks, Common, normal body response to
pregnancy. It could be wrong date as well since you got the womb larger than it should be.
• It could be due to multiple pregnancy
• Or could be due to [Link], not true pregnancy, no fetus, parts of fetus and vesicles, producing
excessive hormones
• Or urinary tract infection (infection in urine tract), appendicitis (inflammation of appendix) ,
gastroenteritis (infection of bowels), peptic ulcers (ulcers in the food bag and bowels) unlikely
• You are in the safe hands now. We will admit you.

Caesarean section counselling

You are a GP, a 24 years old Grace came to see you to discuss about Caesarean section and natural
birth. She is about 20 weeks pregnant. It is her first pregnancy.
Your tasks:
• Take history
• Discuss risks and benefits of C-section
• Explain further management for her concerns
History
• How is your pregnancy going so far? Is this your first pregnancy? Any tummy pain, bleeding,
discharge? How was the antenatal checks? 18 week ultrasound? (number of fetus, placenta
location), Are you attending antenatal clinic regularly?
• Do you have any underlying medical conditions? Any surgeries before?
• SADMA. Social support

• Explain – C-section –draw a pic, Surgery under anaesthesia, make an incision, on the lower
tummy, lower segment of womb, and take out the baby.
• Indications - it has specific indications such as baby -, cephalopelvic disproportion where the
mom hip girdle is too small for the baby to pass through, cord prolapse, meconium staining
which is a sign of baby in distress, abnormal heart rates in the baby, twins, breech, placenta
praevia where the placeta is covering the birth canal etc. Mom – medical diseases like diabetes,
hypertension and infections in Mom
• But we do respect the request of our patient
• Natural birth is through the birth canal as naturally
• Compare -

• Incontinence – there are pelvic floor exercises after birth to prevent incontinence in the future
(Kegel exercises are very effective). They happened more with the big babies and multiparity.
• Pain – we have pain control measures which are adequate
• There is a range of options for pain relief in labour including non-medical techniques and
medical pain relief options such as nitrous oxide, pethidine and epidural anaesthesia. (which is
injection of numbing agent into the spinal cord from back bone)
 • Particularly if you are having your first baby, consider all options and be flexible
• The final choice is yours
• Refer – If you want to know more, I will refer you to a specialist
• Please talk to your family as well

VBAC
You are a HMO. A 20 weeks pregnant lady presents to your rural hospital 400 km away from tertiary
hospital to discuss delivery. She has specific conditions for delivery. She wants her whole family to be
with her during labour. She wants to have music and candles and does not want any doctor or nurse
to assist, does not want to take any medication or injections, wants the placenta to be delivered by
itself and doesn’t want it to be handled by medical staff.
• Tasks
• take further history for 5 mins.
• Counsel the patient.

• One of my candidates said it’s VBAC (I still need more info) So I added notes about VBAC

• You need to first ask a brief history (which I have covered over here) especially regarding her
previous deliveries.
• How many deliveries did she have?
• Did she have any vaginal birth? (If yes you can tell her while counseling that her chances of a
successful VBAC delivery increases up to 90%~9 in 10 women)
• Detailed history about her previous cesarean section eg: why did she have it? What kind of cut
was made? How was the post operative period- was there any fever, blood transfusion or
prolonged stay?
• Always enquire how the babies are doing now. (You may suddenly discover that a baby died
during birth and then you would be more cautious in dealing with her).
• How is the present pregnancy? (Does she know where the placenta is located? Any other
maternal complication like PIH, GDM~Rule out a big baby)
• How many babies is she planning to have in the future? It’s important to get an idea about this.

• Your previous CS was due to ……………. Let me tell you about

• Repeat cesarean Vs VBAC– Briefly describe all the advantages and disadvantages
• Advantages- greater chance of vaginal birth in future, recovery quicker, hospital stay shorter,
more chances of skin to skin contact with baby, reduced initial respiratory distress for the baby.
• Disadvantages- May need emergency cesarean (1 out of 4 women) which varies more risk than a
planned one, blood transfusion, rupture uterus, need for assisted delivery, risk of 3rd/4th
degree tear and a slightly increased risk of stillbirth or brain injury to the baby.
• Success rate of VBAC (75%)
• chances of going into labour before the planned date (10%).
• Factors that increase success – low BMI, previous vaginal birth, labour starting naturally.
• If the C/S was for a breech presentation, fetal distress, poor progression etc. (i.e. not for
cephalopelvic disproportion (CPD)) one can expect a 70% success rate in a trial of vaginal
delivery!
• If the previous C/S was due to CPD the success rate drops to 50%.
• There is a risk of uterine rupture: 0.5% in lower segment C/S and 5% in classical C/S.
 • If VBAC is the chosen method, the delivery should happen in an appropriate hospital with
appropriate staff and equipment because a trial of delivery is on average terminated by C/S in
20% of cases! It will not be possible without the presence of the doctors and nurses, or will not
be possible to wait the baby and placenta delivered themselves without the help of the
medical persons as 25% ended up with induction and 25% with Caesarean section. Needs
continuous monitoring. (address her concern)

Induction of labour
You are a general practitioner. Your next patient is a 25 years old Flora, with 35 weeks pregnancy,
wants to deliver at 36 weeks for family reasons. She has her husband going a long term foreign trip.
Patient would like to make sure that husband can enjoy the birth of first child before his trip and also
she wants her delivery with her husband by her side. She wants your advice. Her AN care is everything
normal.
Your tasks:
• Talk to the patient about her concern

• I do appreciate your concern. It is that you want to deliver the baby, earlier than the expected
dates,i.e, before the onset of labour, we call it Induction of labour.
• Firstly we have to make sure that mom and baby are healthy by taking more history and physical
examination and some investigations.
• Let me explain about the induction of labour.
• IOL is recommended in some reasons – medical conditions such as increased BP, DM , clotting
problems in mom, post term in baby (no onset till term), reduced movements of the baby
• On the other hand, other situations that the patient shouldn’t have induction of labour –
previous CS, any obstruction in birth canal, small pelvis, big baby, Active infections in birth canal
• Procedure –
• Tertiary hospital – obstetrician and neonatologist
• Facility for emergency CS if not successful
• Medical induction – prostaglandin put in posterior part of down below to ripen the cervix
(opening of womb)
• After a few hours, once it opens to 2-3 cm, we do surgical induction – membrane covering the
fetus is ruptured artificially by using forceps or gloved fingers
• It relieves the natural chemicals that progress the labour
• If needed, it will be augmented by medication (syntocinon)
• The progress is noted
• Most patients – successful
• Few – implications
• Sometimes- labour is prolonged and ended up with assisted/instrumental delivery
• Rare cases – fetus cannot tolerate the stress of labour – emergency CS – higher risk of infection,
bleeding, injuries to nearby structures than elective
• Baby is delivered before full term – risk of infection and breathing problems, feeding problems
• Benefits- your husband can enjoy as your concern and he can fully support you, you can set time
and date for delivery
• It is the best to keep the baby inside the womb until it is matured unless there is in need of
urgent delivery – no feeding problems, no breathing problems, no side effects of medications
(Synto – Fetal distress and neonatal jaundice, increased yellow pigment in blood)
 • 1st discuss with partner
• Final decision is yours
• Refer to Obstetrician
• Red flags – any discharge, bleeding, tummy pain - ED

Hypertension in pregnancy
• You are a locum GP in a suburban general practice. Your next patient is a 25-year-old Mrs.
Jones in her first pregnancy who presents for a general check-up at 30 weeks. The practice
nurse has noted a BP of 175/100, P of 72, RR 20, T 37. At previous antenatal visits she had
been quite well with normal vital signs and urine office tests.
• Your task is to:
• Take a focused history
• Perform an examination
• Explain your diagnosis and management plan to the patient.

History:
• Is my patient hemodynamically stable? I would like to know all the vital signs (If she develops fits
while talking rectal diazepam 5-10 mg.) I would like to ask some history from the patient.
• Are you fine now? Please tell me if you’re having symptoms like headache, blurring of vision,
Tummy pain, or back pain, bleeding from down below and swelling in the hands and face? Any
swelling of your ankles?
• How is your pregnancy till now? Any issues? Have you had all regular antenatal checkups? USD?
Blood tests? Sweet drink test? Do you feel the baby kicking? -
• Have you noticed any decrease in the urine out put? Have you noticed that ur urine is somewhat
frothy? Have you noticed any leaking from down below? – Have you broken waters?
• Ask about past history of high BP or family history of high BP? Any medical or surgical condition?
Before this pregnancy, have you ever been diagnosed with high blood pressure, kidney
problems, DM or any other conditions?
• FHx of similar condition? SADMA? – very important. Blood group, (How far are you from the
hospital? Where do you live?)

Physical Examination:
• GA-Pat. looks well, no obvious peripheral oedema, edema of limbs, periorbital, pallor
• BP is indeed 175/110, P 72 and regular, afebrile, SaO2 98% on room air.
• CVS- any added heart sounds or murmurs, RS- Air entry on both sides
• Fundoscopy, CNS- Hyperreflexia, clonus (more objective than reflexes)
• Abdomen- look for any hepatic tenderness, FH (37 cm –corresponding to gestational age),
Uterine tenderness,, fetal movements, presentation and position, FHR
• Speculum done only if there is PV discharge or bleeding or contraction
• Office tests- Urine dipstix (positive for proteins), BSL(Normal)

• Investigation:
• Urinalysis (proteinuria – sign of capillary permeability, casts and cells), LFTs, Uric acid, UECs, FBE,
Coagulation profile, CXR (ARDS), ECG, CTG, U/S, Blood grouping and hold just in case she
requires it.
 • Spot urine PCR - A spot urine protein/creatinine cut-off level of 30 mg/mmol equates to a 24-h
urine protein >300 mg per day.

• From the history that u have told me and the examination finding I got from examiner I am
suspecting that you are having pre-eclampsia. It is condition characterized by a sharp rise in BP
associated with leakage of protein through urine and edema between the 20th week of
pregnancy and the end of the first week postpartum.
• The exact cause is unknown but could be due to certain chemicals released by the placenta,
which causes damage to the blood vessels of various organs affecting maternal liver, kidneys,
brain and clotting system and placental dysfunction.
• What I am worried is that if its not controlled, it can lead to fits i.e. fully blown eclampsia. It can
also effect the baby due to reduced Oxygen and blood supply to the baby.
• Aim of treatment: prevent development of fits. Aim of treatment if with fits: deliver the baby
• Risks of severe pre-eclampsia/hypertension
• Maternal risks (poor control)- Kidney failure, Cerebrovascular accident: seizures, stroke, Cardiac
failure, Coagulation failure, Abruptio placentae.
• Risks to baby - Hypoxia, Premature delivery, IUFD

• Pre-eclampsia
• Give the first dose of antihypertensive (Nifedipine)
• Transfer the patient to hospital and Monitored BP 4 hourly, Urine protein twice daily, Fluid I/O
chart. Bed rest with toilet privileges
• USG, CTG should be arranged. Blood test needs to be done
• Anti hypertensive- Nefedipine (oral),Methyldopa (oral), Labetalol (oral)
• Some patients may need anti hypertensives through veins too.
• Once stable, depending upon the GA, she can be discharged but should be managed as high risk
pregnancy.(but sometimes the patient needs to be admitted until delivery)
• After 37 weeks, specialist might decide to do termination of pregnancy.

Another case - Severe eclampsia in GP

• I need to refer u to a tertiary hospital Monitored BP 4 hourly, Urine protein twice daily, Fluid I/O
chart. I would like to put the patient on the left lateral position and call for help., give oxygen,
take sample, Start Iv Give IV diazepam.
• Give first dose of anti HTN. Nifedipine (10-20mg oral) repeat after 45 mins, IV hydralazine, IV
labetalol
• Admitted to hospital, seen by a specialist- USG, Cardiotocography (for baby) will be done.
Continuous CTG monitoring should be considered in these situations, particularly when there is
evidence of existing fetal compromise
• Then further doses of IV hydralazine, IV Magnesium sulphate to prevent her from getting fits.
MgSO4 50% 4 g IV (given over 10-15 minutes) followed by an infusion 1 g/hour for a minimum
of 24 hours after last fit (if normal kidney function).
• Notes : Aim is to keep the BP between sBP to 130–150 mmHg and dBP to 80–100 mmHg (add
beta-blocker if with tachycardia) because greater reduction can cause fetal ischaemia. There is
concern that a precipitous fall in blood pressure after antihypertensive treatment, particularly
intravenous hydralazine, may impair placental perfusion resulting in fetal distress. This can be
 prevented by co-administration of a small bolus of fluid e.g. normal saline 250mL, at the time of
administration of antihypertensive therapy.

Pre-eclampsia
You are a HMO. 36 weeks pregnant lady with hypertension 150/100mmHg and proteinuria. Obstetric
exam and fetal heart rate already done. Head is 0/5 palpable per abdomen and fundal height is 36 cm.
FHS – 140 bpm.
Tasks:
• Take history for 3 mins
• What further examinations you would do. Explain the instruments you would use.
• What investigations would you order.
• Tell the patient of the most likely diagnosis.

History:
• Is my patient hemodynamically stable? I would like to know all the vital signs (If she develops fits
while talking rectal diazepam 5-10 mg.) I would like to ask some history from the patient.
• Are you fine now? Please tell me if you’re having symptoms like headache, blurring of vision,
Tummy pain, or back pain, bleeding from down below and swelling in the hands and face? Any
swelling of your ankles?
• How is your pregnancy till now? Any issues? Have you had all regular antenatal checkups? USD?
Blood tests? Sweet drink test? Do you feel the baby kicking? -
• Have you noticed any decrease in the urine out put? Have you noticed that ur urine is somewhat
frothy? Have you noticed any leaking from down below? – Have you broken waters?
• Ask about past history of high BP or family history of high BP? Any medical or surgical condition?
Before this pregnancy, have you ever been diagnosed with high blood pressure, kidney
problems, DM or any other conditions?
• FHx of similar condition? SADMA?
• Blood group, (How far are you from the hospital? Where do you live?)

Physical Examination:
• Your BP is high so it contains some risk to the pregnancy. I need to examine you.
• Equipment – Fundoscopy, Hammer, speculum and stethoscope
• I will check for swelling in limbs
• CVS- any added heart sounds or murmurs,
• RS- Air entry on both sides
• Fundoscopy – look into your eyes with a device and checking for any changes in the eyes as
complications of hypertension
• CNS- Hyperreflexia, clonus – I will check for reflexes of the tendons with a medical hammer
which will not harm you
• Abdomen- look for any hepatic tenderness which is feeling of your liver for any tenderness
• Speculum which is looking into your down below will be done for any signs of labor and status
of your birth canal
• Office tests- Urine dipstick if not done yet (positive for proteins), BSL

• Investigation:
 • Urinalysis (proteinuria – sign of capillary permeability, casts and cells), LFTs, Uric acid, UECs, FBE,
Coagulation profile, CXR (ARDS), ECG, CTG, U/S, Blood grouping and hold just in case she
requires it.
• Spot urine PCR - A spot urine protein/creatinine cut-off level of 30 mg/mmol equates to a 24-h
urine protein >300 mg per day.

• From the history that u have told me and the examination finding I got from examiner I am
suspecting that you are having pre-eclampsia. It is condition characterized by a sharp rise in BP
associated with leakage of protein through urine and edema between the 20th week of
pregnancy and the end of the first week postpartum.
• The exact cause is unknown but could be due to certain chemicals released by the placenta,
which causes damage to the blood vessels of various organs affecting maternal liver, kidneys,
brain and clotting system and placental dysfunction.
• What I am worried is that if its not controlled, it can lead to fits i.e. fully blown eclampsia. It can
also effect the baby due to reduced Oxygen and blood supply to the baby.
• Aim of treatment: prevent development of fits. Aim of treatment if with fits: deliver the baby

• Risks of severe pre-eclampsia/hypertension

• Maternal risks (poor control)- Kidney failure, Cerebrovascular accident: seizures, stroke, Cardiac
failure, Coagulation failure, Abruptio placentae.
• Risks to baby - Hypoxia, Premature delivery, IUFD

Preterm labour
Sarah is a 27-year-old female and presents to a district hospital where you work as HMO in ED. She is
32 weeks pregnant and noticed few contractions and cramps in the lower abdomen since yesterday.
She didn't break her water and the baby is kicking well.
Tasks:
• History
• Physical examination
• Advise on management

Notes:
• Preterm labor:
• Gestational period is less than 37 completed weeks.
• Uterine contractions preferably recorded on tocograph occur every 5-10 minutes, last for at
least 30 seconds - 1 min and persist for at least 60 minutes.
• Cervix is more than 2.5cm dilated and more than 50-75% effaced.

History:
• Pain - Since how long? What type of pain it is? Is it constant or does it comes and go? How
often? How often or how long does it last? (every 5 minutes’ duration: 30sec for 1hour)
• Any leakage of fluid down below? Any bleeding? How was your pregnancy up till now? Is the
baby kicking?
 • Infections – have you been diagnosed with any infection recently, any fever? Any burning
sensation while passing urine?
• Pre-eclampsia – any headache? Blurring of vision?
• how is your general health? Any bowel problems?
• Causes - Cervical Incompetence: previous Gynae or surgical procedure? Any natal checks -
Multiple pregnancy, Polyhydramnios, IUGR? Any trauma? Any recent sexual intercourse?
Have you lifted any heavy weight recently?
• Blood Group?
• Physical examination
• General appearance
• Vitals
• Abdomen: lie, presentation, FH, head is engaged or floating, FHR
• Abdominal palpation to assess uterine tone, tenderness or contractions; to assess duration,
strength and regularity.
• Pelvic:
• Inspection: discharge, bleeding
• Speculum: discharge, bleeding, cervical os, nitrazine test
• Digital vaginal examination to assess effacement, dilatation and station. If the membranes are
thought to be ruptured, a digital examination should be avoided until labour is established.
• Investigations
• FBE: signs of infections ESR/CRP, Urine MCS
• High vaginal swabs should be taken be taken for bacteriological assessment and a low vaginal /
ano-rectal swab for group b streptococcus screen. GBS Screen
• Nitrazine test or amnisure
• Ultrasound (Abdomen)
• Blood grouping / Rh
• Fetal fibronectin( labour in 7-14 days)
Management
• Most likely you are in labour. There can be multiple reasons for that. Sometimes it occurs before
term and sometimes after term. Labour usually occurs around 40 weeks, but when it occurs
before 37th week, then we call it as PTL
• It is risky for your baby because your baby is not mature yet. Our target is to delay labour as far
as we can.I will do baseline blood checks and I will give you some medications to stop these
contractions after talking to the specialist. I’ll give you some steroids injection for your baby’s
lung maturation – prevent respiratory distress after birth.
• But most important thing is to transfer you to a tertiary hospital because they have facilities for
preterm babies.

PPROM
You are the night resident in the obstetric unit in a rural hospital. when a 27 years old primigravida,
Sharon, is directly admitted via the ED because her water broke a couple of hours ago at 35 weeks of
pregnancy.
Your tasks:
• Take a history
• Examine the patient
• Arrange for necessary investigations
 • Explain the diagnosis and management to the patient

• Outline of approach
• how long? do you have the discharge? How much (how many pads? Are they fully soaked)?
What is the color (is it clear? associated mucus? Blood? Greenish material? Meconium. Is it
smelly? Is there any tummy pain? Contractions? Any trauma? What were you doing at that
time?
• DDx - Any other associated water works problems (e.g. increased frequency of urination?),
any vaginal secretions?
• Chrio-amnionitis - Fever? Hot flushes? Dizziness? Vomiting? Heart-racing? (
• Do you still feel the baby kicking?
• Pregnancy: is this the first pregnancy? Any miscarriages before? Previous antenatal checkup?
Any abnormalities on USG? What is your blood group? Previous deliveries and previous
gynecological problems?
• Past medical, Surgical? How far do you live from here? Who can care for you if we decide to
transfer you to a tertiary hospital?

• General appearance, pallor, anxious,

• Vital signs: temperature, BP (postural drop), pulse, RR, temp (for infection)
• CVS and Resp examination
• abdomen: inspection, superficial palpation (tenderness means chorio-amnionitis), Fundal height,
feel fetal parts, check fetal position, fetal heart sounds.
• CTG
• Urine dipstick
• Pelvic examination – inspection – fluid? Color? Smell?
• Sterile speculum examination (fluid at fornices). Can I ask the patient to cough to see if there is
any urinary leak? Prolapse of cord?
• Cervix: os status, high vaginal swabs and low vaginal swabs
• confirm the diagnosis by nitrazine/litmus test. (If confirmed, collect amniotic fluid for fetal
maturity tests (lecithin and sphingomyelin or L/S ratio).
• Digital examination – best avoided until the labour
• Other tests - FBE, U/E, LFTs, CRP, CTG, USG
• Your condition is most likely breakage of the waterbag before the labour and also the baby is
not term yet. So we call it PPROM (preterm premature rupture of membrane)
• I will make a call to the specialist and the specialist will decide whether to start the antibiotics,
erythromycin for 10 days.
• If there is no evidence of infection or no contraindication for tocolysis after specialist comment:
I will give the medications to stop contractions, nifedipine/salbutamol and continues the
pregnancy; (deliver if signs of infection.)
• And also a dose steroid for lungs maturation in the baby
• And transfer to tertiary hospital for close monitoring, check for infections and fetal wellbeing,
and continue the pregnancy
• If fetal deterioration or infection present, deliver by LSCS.

Small for date

You are a GP. A 28 years old lady, Lola, visited you for AN care. She is 38 weeks pregnant.
Tasks:
• measure the fundal height,
• take history
• give probable diagnosis.

• When measure the fundal height, it was 34cm. Small of gestational age. Please check the lie – it
could be transverse lie.
• If longitudinal – fundus lesser than dates
• History – 5 P questions including AN care
• Is the baby kicking well?
• Causes – lesser fluid around the baby (oligohydramnios) – any watery discharge (asking for
rupture of membrane?)
o Malformations in the baby (ask for maternal infections, exposure to pets, rubella status
of mom, medical diseases including SlE – ask for joint problems, heart problems, kidney
problems or increased blood pressure, anaemia, nutritional deficiency)
• SADMA in mom

• Explanation – the size of the tummy is smaller than it should be. IT could be because of
decreased fluid around the baby or the baby itself is small.
• If this is decreased fluid around the baby, it is associated with urinary system anormalies in
baby, rupture of membrane or placenta insufficiency.
• If this is a small fetus, it could be wrong date, IUGR due to medical diseases in mom like heart,
kidney, joint, blood pressure problems in mom or infections in mom like toxoplasmosis or
nutritional deficiency.
• We will run blood tests, USG and CTG to know the cause and fetal wellbeing

Large for date

You are in GP and 34 weeks pregnant lady, Kelly, come for antenatal checkup. Ur colleague saw her at
last appointment when she was 28 weeks and her FH at that time was 30 weeks. Now she is 34 weeks
and SFH is 38 weeks. All the blood tests and USG have been done which are all normal. (some cases
came up with gaining weight more than she should)
Tasks
• Take further history
• -Ask PE findings from examiner, where examiner will give u what u are asking for
• -Explain possible causes of this condition to patient

• Greetings
• Pregnancy -How’s your pregnancy so far? Antenatal checks? Blood group? What about 18 week
USG? (how many fetus, placenta location) What about sweet drink test? Any repeated USG
done after 30 weeks? Did you take folic acid? Do you feel your tummy is larger than it should
be?
• Complications of pregnancy - any tummy pain, vaginal bleeding or discharge? any headache,
blurring of vision or leg swelling? any fever, nausea or vomiting? any burning sensation while
passing urine? Any difficulty in breathing? Is the baby kicking well?
 • Other causes – any history of fibroids? Did you have your dating scan? Do you think you look
pale? Any exposure to pets and eat uncooked meats? Recent travel? Family history of large
babies? Weight and height of you and your husband?
• SADMA
• Physical Exam
• -General appearance
• -Vital signs
• -CVS and respiratory
• Obstetric examination – Fundal height, Palpation – tenderness, contractions, lie, presentation,
engagement, FHS
• Pelvic: inspection and speculum
• Most likely you have a larger womb than it should be at this week of gestation. be.
• There are several reasons : it could be due to polyhydramnios or an excessive amount of fluid
around the baby. Infection, birth defects or DM can cause excessive amounts of fluid.
• Others possibilities :
• Wrong dates but less likely because you had your dating scan. Twin or multiple pregnancy, big
baby or fibroids but less likely according to your USG results.
• Mx – we will repeat USG to confirm, CTG for wellbeing of the baby, infection screening, blood
sugar. You will need more frequent visits, check with the specialist, and steroids injections
because there are some risk of preterm labour and unusual presentation.

Placenta Praevia 1
You are an HMO in a hospital OBs-and-Gynae unit and your next patient is a 26-year-old, Tiffany, 24
weeks pregnant who came in due to per vaginal bleeding for 1 hour.
Tasks:
• Relevant history
• Physical examination
• Explain the possible cause

• Stability?
• Bleeding history
• Any tummy pain? Headache? Dizziness? Sweating? Palpitations? History of trauma? Have you
broken your waters?
• Pregnancy: how is your pregnancy going so far? Is it a single pregnancy? Planned pregnancy?
Significant findings in 18-week ultrasound? Position of placenta at that time? How was your
sweet drink test? Is the baby kicking? Previous pregnancy? How was placenta in previous
pregnancy?
• 5 P (not very relevant for this case)
• Are you aware of your blood group? (for aniti-D)
• Social history: how far are you staying from the hospital and do you have enough support?
Bleeding disorders?
• SADMA? – important for causes

Physical examination
• General appearance: pallor, dehydration and jaundice
• Vitals: sitting and standing BP, RR, PR, T, oxygen saturation
 • If with postural hypotension: I would like to insert 2 IV bore cannulas, take blood for blood
group and cross matching and start IV fluids
• Abdomen: FH (whether it corresponds to gestational age), Lie, Presentation, Tenderness of
uterus, Engagement / floating, FHR
• Pelvic exam:
• No Per Vagina Exam (Bimanual)
• Urine dipstick and BSL
• Diagnosis and Management:
• Most likely, I think you have placenta previa. Placenta previa is an obstetric complication that
occurs in the 2nd half of pregnancy. Placenta is normally attached to the upper pole of the
womb but when it is attached to the lower pole of the birth canal, it is called PP. In many cases
the cause is not know but there are certain risk factors like
• Smoking
• Previous placenta previa
• Previous cesarean section
• Multiparity
• Advanced maternal age >35
• Multiple pregnancy
• It can cause serious complications in both mom and baby. Complications are shock due to blood
loss, pre mature labour, IUGR, isoimmunization. In baby hypoxia or decreased O2 supply.
• Reassure
• At this stage, I would admit you, put 2 IV lines and take blood for FBE, blood grouping and cross-
matching and hold, UEC and coagulation profile, LFTs, RFTs,((( Indirect coombs tests, Kleihauer
test (Rh negative mom)))))
• USG to check the degree of praevia and look for any concealed abruption. CTG for the baby.
• I will call the Ob & Gynae Registrar to come and have a look at you. We need to organize an
urgent USG to see the position of the placenta and the O&G registrar might also consider doing
CTG to check the status of baby.
• Will it be possible to deliver my baby vaginally?
• That depends on USG result. If we found the the placenta is completely covering the birth canal,
Normal Vaginal Delivery will not be possible.
• We will wait to see if, if the bleeding stops and when every thing will be normal then we will plan
a CS at 37 weeks. Till than u have to be admitted n the hospital.)

Notes:
• Placenta Previa:
• Grade 4- Total placenta previa (completely obstructs the cervical os)
• Grade 3- Partial Placenta previa (partially obstructing the cervical os)
• Grade 2- Marginal (just at the beginning of the os)
• Grade 1- Low-lying placenta (placenta is implanted in the lower uterine segment. In this
variation, the edge of the placenta is near the internal os but does not reach it)

Placenta praevia 2
You are an HMO in a hospital OBs-and-Gynae unitof a Metropolitan hospital and your next patient is a
26-year-old, Tiffany, 34 weeks pregnant who came in due to per vaginal bleeding for 1 hour. Till now,
her vitals are stable. This is her second pregnancy and in her first pregnancy, she needed to go
through C/S because of the breech presentation. Her antenatal blood tests were the blood group O
negative, no anaemia, no infections and LFT and RFT are normal.
Tasks:
• Explain the investigation result
• Explain the possible causes of this condition
• Management

Ultrasound report
• Fetal maturity 34 weeks 3 days +/- 2 weeks
• Fetal heart rate is 136bpm. Fetal somatic activity normal. Cephalic presentation.
• Amniotic fluid is adequate for this gestation.
• Placenta is anterior, implanted in lower segment, fully covering the internal os.
• No evidence of intra/retroplacental haemorrage is seen.
• Retroplacetal hypoechoic zone is present at the moment.
• No apparent anormaly of fetal skull and spine is noted.
• Impression – single live fetus at 34 weeks 3 days with placeta praevia

• Stability?
• Bleeding history
• Any tummy pain? Headache? Dizziness? Sweating? Palpitations? History of trauma? Have you
broken your waters?
• Pregnancy: how is your pregnancy going so far? Is it a single pregnancy? Planned pregnancy?
Significant findings in 18-week ultrasound? Position of placenta at that time? How was your
sweet drink test? Is the baby kicking? Previous pregnancy? How was placenta in previous
pregnancy?
• 5 P (not very relevant for this case)
• Are you aware of your blood group? (for aniti-D)
• Social history: how far are you staying from the hospital and do you have enough support?
Bleeding disorders?
• SADMA? – important for causes

Explain the ultrasound result

• In your USG, the gestational age is consistent with 34 week + 3 days, the fluid around the baby is
adequate and the baby’s heart rate is normal. The baby is head presentation which is the usual
presention.
• What I’m concerned is that the placenta is located in the wrong place which is called placenta
praevia. I will explain it. The good thing is that there is no sign of separation of the placenta
which is a risky condition.

Diagnosis and Management:

• Placenta previa is an obstetric complication that occurs in the 2nd half of pregnancy. Placenta is
normally attached to the upper pole of the womb but when it is attached to the lower pole of
the birth canal, it is called PP. In your case it’s also covering the opening of the womb totally
which we call Grade 4. As the baby is getting bigger, and it’s head compressing on the placenta,
it causes bleeding.
 • In many cases the cause is not known but there are certain risk factors like
• Smoking
• Previous placenta previa
• Previous cesarean section
• Multiparity
• Advanced maternal age >35
• Multiple pregnancy

• In your case, most likely it’s because of previous C/S (depending on your own positive history)

• It can cause serious complications in both mom and baby. Complications are shock due to blood
loss, pre mature labour, IUGR, isoimmunization. In baby hypoxia or decreased O2 supply.
• Reassure
• At this stage, I would admit you, put 2 IV lines and take blood for FBE, blood grouping and cross-
matching and hold, UEC and coagulation profile, LFTs, RFTs, Indirect coombs tests, Kleihauer test
(Rh negative mom)
• CTG for the baby.
• I will call the Ob & Gynae Registrar to come and have a look at you. The O&G registrar might
also consider doing CTG to check the status of baby.
• We will give you steroid injections because there is a possible preterm delivery
• Anti D will also be necessary since you are a RH negative mother to prevent the reactions
between different blood groups of you and the baby.
• Blood transfusion if necessary, iron infusion if necessary
• Regular observations will be done for any more bleeding, any contractions, baby’s well being,
urine and bowel activities and blood tests (coagulation) and prolong the pregnancy as long as
possible.
• Some women can be discharged after full assessment and specialist opinion and have to stay
near the medical facilities. Women needs to continue bed rest after discharge.
• Or we will deliver the baby by CS if any signs of labour
• Will it be possible to deliver my baby vaginally?
• No. in Grade [Link] we found the the placenta is completely covering the birth canal, Normal
Vaginal Delivery will not be possible.
• We will wait to see if, if the bleeding stops and when every thing will be normal then we will plan
a CS at 37 weeks. Till than u have to be admitted n the hospital.)

Abruptio Placentae
You are an HMO in ED and a young primigravida who is 30 weeks’ gestational age comes to see you
because of vaginal bleeding on examination, she is stable and vitals are normal. Abdomen is not tense
but slightly tender.
Tasks:
• Focused history
• Explain condition to patient
• Management

• Differential diagnosis- In any case of acute abdomen in a heavily pregnant lady- think about
• Premature labor
 • Placental Abruptio
• Trauma
• Torsion
• UTI
• Red degeneration of fibroids
• Placenta Previa
• Appendicitis
• Bowel obstruction

History
• I understand that you are stressed. Before I answer your questions, I would like to ask you a few
details regarding your pregnancy.
• Bleeding -When? How many pads have you used? How soaked were they? Any clots? What
was the color? still bleeding? Any bleeding disorders ? dizzy or palpitations? any bleeding
disorders in you or the family? What were you doing when it started?
• pain? When did it start? How bad is it on a scale of 1-10? arrange a pain killer, after asking for
any allergy. where exactly is the pain? continuous or come and go? Aggravating or relieving
factors? Is it worsening? Do you think this pain is associated with N/V/headache/ dizziness?
• Any gush of water coming out with the blood?
• Pregnancy: how is your pregnancy going so far? Is it a single pregnancy? Planned pregnancy?
Significant findings in 18-week ultrasound? How was your sweet drink test? Is the baby kicking?
• Previous pregnancy? How was placenta in previous pregnancy?
• Signs of Pre-eclampsia: Persistent headache, Abdominal tenderness, Drowsiness, Visual
disturbances
• Complications – Coagulopathy (bleeding)? If present – Last time pass urine ? (renal failure)
• What is your blood group? (feto-maternal haemorrage) What is your husband’s blood group?
Have you received any anti-D injections up to now? Are you regular with your pap smears?
SADMA

• General appearance: pallor, dehydration and jaundice

• Vitals: sitting and standing BP, RR, PR, T, oxygen saturation
• If with postural hypotension: I would like to insert 2 IV wide bore cannulas, take blood for
blood group and cross matching and start IV fluids
• Abdomen: FH (whether it corresponds to gestational age), Lie, Presentation, Tenderness of
uterus, Engagement/floating, FHR, Palpate for uterine contractions or tenderness.
• Pelvic exam:
• Inspection: discharge, is there any blood trickling out or in gush, color, clot, signs of trauma,
fluid discharge
• Sterile Speculum: discharge, blood, cervical os (if open or close);
• Bimanual examination is preferably avoided until an ultrasound has been obtained
• Urine dipstick and BSL.

• From the history and examination findings I am suspecting that you have a condition called a
mild placental abruption. Draw diagram.
• Normally placenta separates after the delivery. In placental abruption, the placenta separates
earlier.
 • In many cases the cause is not know but there are certain risk factors like
• Smoking
• Previous placenta previa
• Previous cesarean section
• Multiparity
• Advanced maternal age >35
• Multiple pregnancy
• Hypertension in pregnancy
• Cocaine abuse
• Trauma
• Previous history of placental abruption
• Poor nutrition
• I would like to admit you. At this stage the bleeding has stopped but the condition is risky.
(problems with blood coagulation and kidney problems) . I will call the OB registrar to come and
have a look. Meanwhile I will secure IV lines and collect blood for investigations.
• If there is no bleeding, we can discharge you and refer you to high risk pregnancy clinic.

MVA in pregnancy
In the emergency department of a small rural hospital you see a 36 week pregnant lady, Mrs. Janice
Cook, who was involved in a motor vehicle crash. She was the front seat passenger with seatbelt on
while her husband was driving. She is conscious and able to sit at up and talk to you. She is
complaining of tummy pain. She has her antenatal notes with her. Her antenatal check up has been
normal so far, including 18 scan.
Your tasks:
• Take a further history
• Examine the patient
• Arrange for appropriate investigations
• Discuss your findings a management with the examiner

• patient hemodynamically stable? I would like to talk to my patient preferably in a resuscitation

cubicle with all the necessary resuscitation equipment. How are you feeling at the moment? Let
me reassure you that you are in safe hands. If you want, I can call someone to be with you.
• tummy pain? When did it start? How bad is it on a scale of 1-10? I would like to arrange a pain
killer for my patient, after asking for any allergy. Can you point out where exactly is the pain?
continuous or does it come and go? Aggravating or relieving factors? Is it worsening?
• (Can I ask more about the accident? When did it happen? How? Who was driving? Were you in
the passenger seat/backseat? How fast was it going? (>60km would be major) Were you
wearing seatbelt? Did you hurt your head?)
• bleeding, or discharge from down below? Any headache, N/V? Is there a wound anywhere on
your body? Did you lose consciousness at any time?
• Pregnancy: how is your pregnancy going so far? Is it a single pregnancy? Planned pregnancy? 18-
week ultrasound? How was your sweet drink test? Is the baby kicking?
• Previous pregnancy? How was placenta in previous pregnancy?
• blood group? Partner’s blood group? Did you receive any injection of anti-D during pregnancy?
Any past history of bleeding disorders, clotting problems, illnesses?
• Physical Examination
• Primary (ABC!) and secondary trauma surveys
 • Vital signs especially BP
• Secondary survey looking for signs of trauma to the bones, joints, vessels (pulses), Inspect for
any visible signs of trauma all over the body? Bruises? Pallor? Dehydration?

• Abdominal examination:
• Inspect for ecchymosis, especially across the lower abdomen, which may indicate a possible
seatbelt injury.
• Fundal height, lie, presentation, FHS
• Palpate for uterine contractions or tenderness.
• Fetal heart tones
• Rebound tenderness and guarding may be less apparent in advanced gestation.
• Pelvic exam:
• Visible bleeding, discharge, signs of trauma, examine for vaginal lacerations, which may signify
an open pelvic fracture.
• Look for bone fragments in the vagina, which signify an open pelvic fracture. Sterile speculum
examination before bimanual examination.
• Perform these in the absence of vaginal bleeding. Test the fluid for pH and ferning. A pH of 7
indicates amniotic fluid. Vaginal secretions are more acidic, with a pH around 5. Nitrazine test (if
pH > 5 normal; > 5-7 amniotic fluid)
• Note : In general, the obstetrician should perform this examination. It should be performed in a
setting where emergency cesarean delivery can be performed.
• Urine dipstick and BSL
• FBE, U+E’s, glucose, ABG, Blood group (if not known)
• Urinalysis, Coagulation studies
• Kleihauer test: This test is used to detect fetal-to-maternal haemorrhage and the amount of
fetal blood cells in the maternal circulation and then a prophylactic injection of anti-D
gammaglobulin should be given!
• Radiologic examinations if any signs of fracture or pain during examination (X-ray of pelvic
girdle) should not be deferred because of the presence of the fetus.
• ECG
• Cardio-tocographic monitoring At least 4 hours to exclude placental abruption (minor cases,
>20 weeks of gestation)
• Note : Resuscitation of the more serious trauma patient must focus on the mother because the
most common cause of fetal death is maternal shock or death.
• Rh(D) immune globulin: Administered if the patient is Rh-negative, unless the father also is Rh-
negative.
• Red flags - Signs of preterm labour
• Abdominal pain
• Vaginal bleeding
• Change in fetal movements

Primary PPH
You are an ED intern A lady who has given birth to her 3rd child has had 1L of blood pass within the
last 5-10 minutes. She has just given birth to a 3.5Kg baby. She has been given 20U Syntocin. During
controlled cord traction the cord broke leaving the placenta inside.
o PEFE
o Explain immediate management to patient
Approach
• Vitals first
• If not stable – ABC check – two wide bore cannulas, Take blood for G and M and reserve 6 units
of blood, IV Normal saline in bolus
• How was the delivery? Baby well?
• PEFE – GA, vitals, Resp, CVS, pelvic examination
• Catheter for full bladder
• Check the lacerations if vaginal delivery
• Check placenta(if already delivered)
• Medical notes for bleeding disorders and medications
• Check uterus – contracted? Size? Firm?

• So you have the bleeding because you still have the placenta inside. So now I will try to massage
the womb and try to take it out by a method called control cord traction after catheterization
for full bladder. Also you will be on another Synto shot to help contract the uterus. The other
drugs for womb contraction like ergometrine or prostaglandin will be given after being checked
by the registrar. (ergometrine is contraindicated in heart disease and hypertension)
• If still not expelled, we will remove manually by exploring and remove gently with hands. If
bleeding still present after successful removal, we can try synto drip (upto 40IU) or bimanual
compression or balloon tamponade and putting sutures on womb or blocking the uterine artery
or ligation of internal iliac to stop bleeding.
• If still not coming out, it could be placenta acreta, where the placeta grows deeply into the
muscle layer of the womb. In that case, the patient may need the removal of the uterus.
(Reassure : Removal of the womb is just the last measure only if all other measures failed and
most women with bleeding got controlled with just few first line measures)

Secondary PPH (endometritis)

• You are a HMO in ED. A 30-year-old lady, Sandra has complained of vaginal bleeding and
38.2’C. 10 days ago, she delivered a baby.
• Tasks :
• Take a focused history
• Ask physical examination from the examiner
• Explain diagnosis and management to the patient

Outline of approach
• Check stability
• Fever – How long? Did you measure? Continuous or off and on? Associated with shaking?
• BPV – when? Fresh or old blood? Amount? Smelly? Dizziness? Bleeding from other areas?
Breathless?
• Delivery – 1st pregnancy? Planned? Boy or girl? How is the baby? Baby term or pre term?
• Pregnancy and delivery uneventful? LSCS or VD? VD - Any assisted delivery? Episiotomy?
Prolonged labour? Massive bleeding after delivery? Any procedure done after delivery?
(Retained products of conception) LSCS – elective or emergency? How long did you stay in the
hospital?
• DDx – breast – breast feeding? Problems like pain, redness, swelling and cracked nipples?
 • -ENT – Headache, cough, cold, running nose
• -Endometritis - tummy pain
• UTI – problem with waterwork? Pain when you pee? Unusual foul smelling discharge?
• DVT – any calf pain?
• Medical history, Social history – supportive? Post partum depression – Any mood changes?
Crying or teary without obvious reason?
• SADMA

• PEFE – pallor, vitals, Blood pressure lying and standing

• Eye and Ent for inflammation, CVS and respiratory,
• Breast – check for mastitis – inspection, palpation, fluctuation test to exclude abscess
• Abdomen – inspection, palpation,
• VE – inspection (bleeding), episiotomy wound, speculum (os, tears, features pf cervicitis or
vaginitis), Take swab (high, low vaginal), Bimanual – uterus size, tenderness, cervical excitation
pain, adnexal tenderness
• Bedside test – urine dipstick to exclude UTI

• Explanation – what I found is fever, slight bleeding from down below, womb tender, lax and
soft, usually it has to be firm, if well contracted. All these point out to infection inside the womb
(endometritis), inflammation of inner lining of the womb. Could be parts of the placenta
remained in womb and became source of infection. Some – already removed, but attachment
site still possible to be source of infection.
• It can be due to other infections or can also be due to normal vaginal bugs overgrowth.
• Risky condition – complications – spread to the birth canal – PID, bleeding can be serious,
Septicaemia (Bugs travels to the bloodstream and affect many other organs. Needs to be
treated ASAP.

• Investigations – FBE, Blood culture, Urine culture, Swabs, USG (RPOC)

• Treatment – IV Oxytocin to help the womb contraction (severe – Ergometrine), Iv antibiotics
(Augmentin, Metro, Gentamycin) before culture and change according to the culture.
• If USG shows – RPOC – D&C – which is a procedure to remove those products of conception
from the down below under analgesia.
• Encourage to continue breastfeeding (risk of mastitis)

Mastitis
You are a GP. A 30 years old lady, Kelly, who had a delivery 2 weeks ago presented to you right breast
pain. She also has a fever.
Your tasks:
• Take relevant history
• Ask physical examination
• Dx to the patient

Approach
• How are you? How is the baby? Planned? Congrats!
• Tell me more about the pain. Are you on breast feeding? Any problem? Any cracked nipple?
redness? Lump? Tender? Hot to touch? Are you still on breast feeding? Stopped due to pain?
 • Is the baby being positioned to the breast correctly? Has somebody taught you the correct
positioning of the baby during breastfeeding?
• Fever – when? How high? Continuous or off and on? Shaking?
• DDx –- Cough, runny nose, sore throat? Tiredness, racing of heart beat? Tummy or loin pain?
Any problem with poo and pee? Pain when you pee? Leg pain, calf muscles pain?
• Delivery history, Wound?
• Mood? Any financial burden
• SADMA

• PEFE
• GA, vital signs
• CVS, respiratory,
• ENT – sore throat
• Breast – focused , both breasts
o inspection – redness, lumps, swelling, cracked nipple, dilated veins
• Palpation – tenderness , temperature, fluctuation test (to differentiate abscess), discharge
• Abdomen – check the wound if present, palpate for uterus site,size, consistency, liver, spleen
and other masses
• Pelvic examination - inspection and speculum for wounds
• Lower limb – cellulitis, DVT
• BST - UDT

Explanation
• Most likely mastitis. It is the inflammation of breast tissue. It is due to lactation and mainly
caused by cracked nipple and poor milk drainage. Bugs from the skin invades through the
cracked nipples causing inflammation of the breast tissue.
• If not treated – may lead to collection of pus and abscess, proliferation of bugs throughout the
blood stream
• So we will manage right now which is the early stage. I will give you antibiotics.
• Management – Can you tolerate the pain? If yes, you can have home treatment
• Antibiotics – if not allergic, Dicloxacin 500mg for 10 days or flucloxacillin
• Pain and fever – Panadol
• Take a good rest, sound sleep
• Try warm packs just b4 breastfeeding ( to relieve blockage), cold packs in between to relieves
pain and swelling
• Increase fluid intake
• Continue breast feeding especially on affected breast to drain milk
• 24-48 hours– review you again
• If pain and fever still present , not improved– check for abscess by USG, if yes, go to surgeon for
aspiration, stop breast feeding for a while and express milk
• 2nd – fungal infection? Blood tests and check discharge swab – antifungal
• Review, reading material